HEALTH  SCIENCES  STANDARD 


HX00035491 


Columbia  ^nibergitp 
in  tije  Citp  of  i^eto  gork  .  ^  . 

College  of  ^Ijpsiiciang  anb  burgeons; 


Reference  Hitirarp 


Dental  Fund 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/injuriesoffacejaOOmart 


INJURIES    OF    THE    FACE    AND 
JAW  AND  THEIR   REPAIR 


INJURIES  OF  THE  FACE 
AND    JAW 

AND    THEIR     REPAIR 

AND  THE  TREATMENT  OF  FRACTURED  JAWS 


BY 


P.    MARTINIER 


PROFESSOR    TO    THE    DENTAL    SCHOOL    OF    PARIS,    DENTIST    TO    THE    SEINE 
ASYLUMS,    HONORARY    DIRECTOR    OF    THE    DENTAL    SCHOOL    OF    PARIS 

AND 

DR.    G.    LEMERLE 

PROFESSOR    TO    THE    DENTAL    SCHOOL    OF    PARIS,    DENTIST    TO    THE    HOSPITALS 


TRANSLATED  BY 
H.   LAWSON  WHALE,   M.D.,  F.R.C.S. 

CAPTAIN  R.A.M.C,  T.  (FORMERLY  CAPTAIN  I. M.S.),  THE  ORAL  DEPARTMENT, 
NO.  S3  GENERAL  HOSPITAL,  B.E.F.  ;  VISITING  SURGEON  TO  THE  THROAT,  NOSE, 
AND  EAR  DEPARTMENT,  THE  COUNTY  OF  LONDON  WAR  HOSPITAL,  EPSOM  ; 
LARYNGOLOGIST  TO  THE  LONDON  TEMPERANCE  HOSPITAL,  .-aND  TO  THE 
HAMPSTEAD    GENERAL    HOSPITAL  \ 


NEW  YORK 

WILLIAM    WOOD    AND    COMPANY 

MDCCCCXVII 


2.^  -   5  5"  ^2-/ 


PRINTED    IN    GREAT    BRITAIN 


TRANSLATOR'S  FOREWORD 

It  may  be  justly  claimed  that  during  the  war  no 
branch  of  surgery  has  emerged  from  oblivion  and 
neglect  to  a  position  of  insistent  importance  to  a 
greater  extent  than  facial  restoration.  The  reasons 
for  the  former  indifference  are  not  far  to  seek.  First, 
traumatic  facial  deformities  were  rare.  Among 
non-traumatic  causes,  epithelioma  is  chiefly  confined 
to  the  lips;  syphilitic  stigmata  to  the  nasal  bridge, 
and  usually  treated  by  paraffin.  The  ravages  made 
by  rodent  ulcer  and  lupus  are  suitable  rarely  for 
plastic,  although  sometimes  for  prosthetic,  correc- 
tion. Thus  the  field  for  plastic  facial  surgery  was 
limited.  And,  secondly,  the  profession  in  Great 
Britain  availed  itself  but  little  of  such  opportunities 
as  offered.  Anyone  frankly  adopting  this  branch  as 
a  speciality  would  likely  have  been  classed  with 
beauty  specialists  and  other  quacks.  It  would  have 
been  urged  (and  still  is  by  inexperienced  critics)  that 
large  facial  gaps  could  only  be  treated  by  prosthesis, 
and  should  be  passed  on  to  the  surgical  instrument 
maker;  that,  as  regards  smaller  wounds,  anyone 
with  the  most  modest  surgical  skill  can  sew  up  a 
face;  and  that  since  this  is  so,  and  the  work  neither 


vi  TRANSLATOR'S  FOREWORD 

involves  serious  surgical  emergencies  nor  depends 
on  a  pathological  basis,  this  branch  can  hardly  be 
called  true  surgery — still  less  major  surgery. 

I  submit  that,  at  any  rate  for  gunshot  injuries, 
this  view  is  wrong.     To  undertake  the  correction  of 
smashed  faces  and  jaws,  from  the  moment  of  their 
arrival  from  the  firing-line  until  they  are  fully  re- 
stored, will  satiate  even  an  ambitious  surgical  appetite 
with  a  diet  of  science  flavoured  with  art.     On  any 
day  the  operator  may  be  confronted  with  an  emer- 
gency tracheotomy,   a  bullet  to   be  removed  from 
the  prevertebral  space,  a  carotid  artery  to  be  Hga- 
tured,  accessory  nasal  sinuses  (including  frontal  and 
sphenoidal)  to  be  opened.     The  next  day  he  may 
be  busy  with  such  delicate  manipulations  as  raising 
the  angle  of  a  mouth,  or  with  undertakings  which 
must  appeal  to  the  spirit  of  a  pioneer — for  instance, 
moving  large   flaps,   and  grafting  fat,   cartilage,   or 
bone.     On  the  scientific  side  the  facial  surgeon  is 
brought    into    contact    with    the    modern   scientific 
product  of  dental  education,  the  oral  surgeon;  and 
with  the  physician  and  bacteriologist,   witness  the 
(alas !    too    frequent)    lung    infections    from    septic 
mouths.     And  on  the  mechanical  side  he  is  in  con- 
stant  collaboration   with   expert   dental  mechanics, 
the   admirable    workmen   who    construct    ingenious 
spHnts  to  build  out  lips,  shape  noses,   and  so  on. 
Truly,    there   is   much   interesting    country   in   this 
surgical  no-man's-land,  the  face. 

The  importance  of  temporary  prosthesis  is  para- 
mount.    Without  its  aid,  it  would  be  quite  impossible 


TRANSLATOR'S  FOREWORD  vii 

to  get  the  results  we  do.  As  to  permanent  pros- 
thesis, we  at  No.  83  General  Hospital  use  it  as 
little  as  possible.  In  a  totally  new  nose  (made  from 
a  rib  cartilage  and  a  forehead  flap),  invisible  dilators 
may  have  to  be  worn  in  the  nostrils,  and  removed 
daily  for  cleansing;  a  loss  of  tissue  in  a  mandible, 
if  unsuitable  for  a  bone  graft,  requires  a  prosthesis; 
and  often  a  gap  in  an  alveolar  margin  has  to  be 
closed  by  a  vulcanite  denture  bearing  teeth.  But — 
as  is  shown  by  our  cases  published  elsewhere — we 
aim  at  building  up  the  face  from  the  patient's  own 
tissues.  The  patient  naturally  prefers  this.  Only 
one  has  elected  to  go  to  England  for  a  permanent 
mask  prosthesis,  rather  than  undergo  a  series  of 
operations. 

Perhaps  a  few  brief  criticisms  of  the  authors' 
views  may  be  allowed.  In  m^^  experience,  secondary 
hemorrhage  is  not  so  pleasantly  rare  as  in  theirs; 
but,  as  they  say  (p.  158),  irrigation  cannot  be  held 
responsible,  ^^e^y  frequent  lavage  is  certainly  neces- 
sary; at  No.  83  it  is  performed  hourly  (p.  188). 
Boiled  water  (p.  323)  is  sufficient  in  many  cases;  but 
it  should  be  under  pressure,  a  forcible  stream.  Major 
Valadier  devised  an  excellent  apparatus  in  constant 
use  here.  A  five-gallon  petrol  drum,  movable  on 
wheels,  is  fitted  with  an  exit  tube  controlled  by  a 
stop-cock,  and  ending  in  a  plated  cannula.  An 
entrance  tube  connects  the  drum  with  a  bicycle 
pump,  which  provides  the  pressure. 

To  prevent  retrocession  of  the  tongue  (pp.  168, 191), 
I  have  never  seen  the  necessity    or  advisability  of 


viii  TRANSLATOR'S  FOREWORD 

the  patient  wearing  a  wire  (attached  to  the  jaw 
appHance  and  passing  through  the  tongue).  Any 
such  arrangement  is  a  constant  source  of  shght  pain, 
and  encourages  sepsis.  Apropos  of  wiring  the  teeth 
of  upper  and  lower  jaws  together,  it  is  pointed  out 
(p.  260)  that  this  makes  it  difficult  to  feed  the  patient. 
I  would  add  to  this  that,  if  he  is  to  be  shipped  to 
England,  it  is  also  difficult  for  him  to  vomit  if  he 
feels  seasick — an  important  detail.  We  share  the 
authors'  respect  for  teeth  in  the  line  of  a  fracture 
(p.  282).  It  is  noticeable  that  they  do  not  discuss 
grafts,  either  for  nose  or  jaw. 

The  suggestion  that  artificial  substances  should 
be  used  for  filling  the  hollows  left  by  frontal  sinus 
operations  (p.  229)  is  not  likely  to  find  general  favour 
among  rhinologists.  It  will  hardly  be  beheved  that 
the  results  are  as  good  as  those  of,  for  instance,  the 
radical  method  of  Killian,  whose  "  bridge  "  operation 
avoids  any  deformity. 

It  will  please  many  readers  that  the  method  of 
paraffin  injection  is  damned  with  faint  praise  (p.  227). 
Indeed,  for  reasons  familiar  to  rhinologists,  this 
practice  is,  in  Great  Britain  at  any  rate,  not  much 
followed  now.  Its  dangers  are  out  of  aU  proportion 
to  the  probability  of  a  permanent  good  result. 

The  authors'  comments  on  total  rhinoplasty 
(p.  234)  seem  unduly  harsh;  we  have  had  very  happy 
results.  The  section  on  prosthesis  for  the  ear 
(p.  141)  is  scanty,  which  accords  \\dth  the  lack  of 
progress  in  this  direction.  The  part  devoted  to 
laryngeal  prosthesis  (p.  107)  is  valuable  as  a  lesson 


TRANSLATOR'S  FOREWORD  ix 

in  mechanical  ingenuity.  But  few  surgeons  of  to-day 
feel  any  enthusiasm  on  the  subject  of  artificial 
larynxes.  After  a  total  extirpation  of  the  larynx 
the  patient's  mental  condition  is  truly  miserable. 
The  keynote  in  the  treatment  of  that  ghastly  afflic- 
tion, laryngeal  carcinoma,  is  earlier  diagnosis.  Then, 
if  operation  be  indicated,  thyrotomy  and  submucous 
removal,  or  partial  resection  of  the  laryngeal  box — 
with  or  without  extirpation  of  lymphatic  glands — 
is  to-day  admitted  to  be  the  procedure  of  choice. 
After  operation,  or  in  cases  where  this  is  contra- 
indicated,  diathermy  and  radium  are  valuable  allies. 

The  section  on  fractures  of  the  upper  jaw  (p.  330) 
is  particularly  clear  and  concise. 

In  their  introduction,  the  authors  are  to  be  con- 
gratulated on  their  frank  admission  that  in  the  text 
they  repeat  themselves,  and  that  they  do  not  apologize 
for  so  doing.  Such  fundamental  truths  as,  for  in- 
stance, that  an  anatomically  restored  jaw  is  useless 
if  physiologically  damaged  by  malapposition  of 
corresponding  teeth  well  bear  repetition. 

In  conclusion,  I  should  like  to  emphasize  that 
facial  work  amply  repays  the  trouble  spent  on  it. 
Many  of  those  maimed  in  this  war  w^ill  require,  on 
their  discharge,  to  canvass  for  civil  employment. 
Human  nature  always  finds  physical  deformity 
repugnant,  facial  disfigurement  especially  so.  And 
the  sufferers  are  likely  to  be  handicapped  if  their 
appearance  is  revolting.  Their  recognition  of  this 
fact  largely  accounts  for  their  extraordinary  patience 
in   undergoing   the   repeated   operations   which   are 


TRANSLATOR'S  FOREWORD 

necessary.  Their  gratitude  afterwards  is  good  to 
see.  It  gives  the  surgeon  real  pleasure  to  note  the 
pride  with  which,  let  us  say,  a  man,  who  had  lost 
his  original  nose,  sneezes  through  a  new  one  made 
out  of  his  own  iiesh  and  bone. 

Any  who  wish  to  verify  this  sensation  of  surgical 
satisfaction  by  undertaking  similar  work  will  find 
this  book  most  useful. 

H.  LAWSON  WHALE,  M.D.,  F.R.C.S., 
Capt.  R  A.M.C.  (T.). 
No.  83  General  Hospital,  B.E.F. 

Sepiaih  er,  1917. 


AUTHORS'  PREFACE 

The  manual  which  we  issue  to-day  has  no  preten- 
sions to  being  a  technical  treatise  on  prosthetic 
restoration.  We  have  merely  endeavoured  to  sys- 
tematize the  innumerable  efforts  at  prosthetic 
restoration  which  have  been  made,  especially  during 
the  last  fifty  years.  Our  principal  aim,  then,  has 
been  to  point  out  the  limitations  of  each  of  these, 
and  to  classify  them.  In  fulfilling  this  object,  we 
feel  no  misgivings  on  the  score  of  having  repeated 
ourselves.  Any  insistent  repetitions  will  be  forgiven 
us  if  we  have  succeeded  in  diminishing  the  regrettable 
confusion  (which  the  practitioner  too  often  en- 
counters) between  methods  sometimes  strongly 
similar  in  appearance,  but  depending  upon  principles 
and  general  ideas  which  are  essentially  different. 

At  the  beginning  of  this  manual  it  is  our  pleasant 
duty  to  salute  the  memory  of  our  master,  Claude 
Martin,  who  has  always  helped  us  in  our  written 
researches  with  a  kindly  and  untiring  supervision. 
The  name  of  this  genius  among  prosthesists  dominates 
the  restorative  art  which  he  practised.  For  out  of 
fragmentary  methods  he  has  pieced  together  schemes 
such  as  that  of  immediate  prosthesis.     And  he  has 

xi 


xii  AUTHORS'  PREFACE 

helped  to  make  surgical  prosthesis  an  essentially 
French  branch  of  our  profession,  and  a  branch  of 
which  the  brilliance  flashes  through  our  land.  We 
thank  our  confreres  Fr.  Martin,  Pont,  and  Delair, 
from  whom  we  have  often  received  contributions, 
and  who  have  allowed  us  to  borrow  extensively  from 
their  work. 

p.  MARTINIER. 
G.  LEMERLE. 


CONTENTS 


PAGE 

translator's  foreword  -  -  .  -         V 

authors'  preface  -  -  -  -  -       xi 

CLASSIFICATION  OF  THE  DIFFERENT  METHODS  OF  RE- 
STORATION BY  PROSTHESIS:  EXTERNAL  PROSTHESIS  ; 
INTERNAL    PROSTHESIS  -  -  -  .      xvii 

PART  I.— EXTERNAL  PROSTHESIS 

SECTION  I.— REMOTE  OR  LATE  PROSTHESIS 

CHAPTER 

I.    CHARACTERS    OF    CICATRICIAL    TISSUE  -  -  3 

II.  BLOODLESS  TREATMENT    OF    VICIOUS  SCARS ;    UPPER 

jaw;  lower  jaw;  results  of  resections  PER- 
FORMED ON  THE  LOWER  JAW;  REDUCTION  OF 
NASAL    DEFORMITIES  -  -  -  -  12 

III.  LATE  prosthesis:    late  prosthesis  OF  the  JAWS  ; 

PROSTHESIS  FOR  THE  SOFT  PALATE  AND  HARD 
palate;  PROSTHETIC  INTERVENTION  AFTER  STA- 
PHYLORRHAPHY; OBTURATORS  ENABLING  NEWLY- 
BORN  CHILDREN,  AFFLICTED  WITH  LABIAL  OR 
PALATAL  FISSURES,  TO  BE  SUCKLED;  CONCLU- 
SIONS -  -  -  -  -  -51 

IV.  LARYNGEAL      PROSTHESIS:      MICHAEL's      ARTIFICIAL 

larynx;  ARTIFICIAL  LARYNX  OF  CL.  MARTIN; 
DELAIr's    APPARATUS  -  -  -  -       10/ 

V.    LINGUAL  PROSTHESIS  :  ARTIFICIAL  TONGUE  ;  SHEATH 

FOR    THE    TONGUE  -  -  -  -       1 24 

xiii 


xiv  CONTENTS 

CHAPTER  PAGE 

VI.    NASAL    PROSTHESIS-  -  -  _  .  128 

VII.    AURICULAR    PROSTHESIS  -  -  -  -  I4I 

VIII.    PROSTHESIS    OF    LIPS  ....  142 

IX.    EXTENSIVE    BUCCO-FACIAL  RESTORATIONS   -  -  1 43 

SECTION  II.— IMMEDIATE  PROSTHESIS 

I.    IMMEDIATE    PROVISIONAL    PROSTHESIS    APPLIED    IN 

THE    CASE    OF    SUBPERIOSTEAL    RESECTIONS  -       1 49 

II.    IMMEDIATE  PROVISIONAL  PROSTHESIS  DESTINED  TO 

OPPOSE    CICATRICIAL    RETRACTIONS  -  -       I5I 

III.  ACCIDENTS    CONSECUTIVE    TO    RESECTIONS    OF    THE 

LOWER    JAW    NOT   FOLLOWED   BY    PROSTHESIS        -       1 52 

IV.  CONDITIONS    WHICH    MUST    BE    FULFILLED    BY    AN 

APPLIANCE    OF    IMMEDIATE    PROSTHESIS    -  -       1 54 

V.    APPLIANCES    OF    IMMEDIATE    PROSTHESIS    FOR    THE 

LOWER    jaw:    CONSTRUCTION    OF   APPLIANCES       -       1 67 
VI.    APPLIANCES    OF    IMMEDIATE    PROSTHESIS    FOR    THE 

UPPER  jaw:  generalities;  description  OF 
appliances;  construction  of  appliances      -     177 

vii.  placing  the  provisional  appliance treat- 
ment  placing  the  final  appliance  -     1 87 

viii.  conclusions  ...  -  -     191 


PART  II.— INTERNAL  PROSTHESIS 

SECTION  I.— INTERNAL  PROSTHESIS 

SECTION  II.— INTERNAL  PROSTHESIS  PROPER 

I.  TOLERANCE  OF  TISSUES  TOWARDS  FOREIGN  BODIES: 
REACTIONS  OF  PERIOSTEUM  AND  BONE  IN  THE 
PRESENCE  OF  FOREIGN  BODIES;  REACTIONS  OF 
THE  TISSUES  ACCORDING  TO  THE  NATURE  OF  THE 
FOREIGN  BODIES;  TOLERANCE  AS  AFFECTED  BY 
THE  SHAPE  OF  THE  FOREIGN  BODY;  TOLERANCE 
DEPENDING  ON  THE  MOBILITY  OF  THE  FOREIGN 
BODY  ......       213 


CONTENTS  XV 

CHAPTER  PAGE 

II.  THE  VARIOUS  MODES  OF  RETENTION  OF  APPLIANCES 
FOR  INTERNAL  PROSTHESIS,  AND  THEIR  TOLER- 
ANCE   BY    BONY    TISSUE    .  -  -  -       222 

III.  PLASTIC    PROSTHESIS  -  -  -  -       22  7 

IV.  PRACTICAL    CONCLUSIONS       -  -  -  -       229 
V.    RHINOPLASTY    OVER    A    METAL   APPLIANCE  I    GENER- 
ALITIES;     CONSTRUCTION      OF     THE      APPLIANCE; 
PLACING     THE     APPLIANCE;     GOLDENSTEIN'S     AP- 
PARATUS; THE  ELEVATION  OF  COLLAPSED  NOSES  -       234 

VI.  CONSTRUCTION  AND  FITTING  OF  APPLIANCES  FOR 
INTERNAL  PROSTHESIS:  GENERALITIES;  INSTRU- 
MENTATION -  -  -  -  -239 


PART  III.— TREATMENT  OF  FRACTURED 

JAWS 

SECTION  I.— FRACTURES  OF  THE  MANDIBLE 

SIMPLE    FRACTURES  -  -  -  -  "       -47 

COMPOUND    FRACTURES  -  -  -  .       248 

I.    SURGICAL    METHODS:    SUTURE    OF   BONE;    LIGATURE 

OF    BONE  ------       249 

II,    PROVISIONAL   APPARATUS:    BANDAGES;    SLINGS;    IN- 
TERDENTAL   LIGATURES    -  -  -  -       ^55 

III.  FRACTURE  APPLIANCES  proper:  APPLIANCES  FIXED 
WITHOUT  PREVIOUSLY  TAKING  .\N  IMPRESSION; 
APPLIANCES  WHICH  NECESSITATE  THE  TAKING  OF 
AN    IMPRESSION,     AND    MADE    ON    A    CORRECTED 

MOULD APPLIANCES     WITH    A     DOUBLE     SPLINT, 

FOR  TEETH  AND  CHIN:  DESCRIPTION  OF  APPLI- 
ANCES; CRITICAL  REVIEW  OF  THE  DOUBLE  SPLINT 
APPLIANCES  MADE  ACCORDING  TO  A  CORRECTED 
MOULD  OF  THE  DENTAL  ARCH APPLIANCE  CON- 
SISTING   OF    A    DOUBLE    DENTAL    SPLINT,    LOWER 

AND  UPPER APPLIANCES  WITH  A  SIMPLE  DENTAL 

splint;  CRITICISM  OF  APPLIANCES  CONSISTING  OF 

A    SIMPLE    SPLINT  -  -  -  -       26 1 


xvi  CONTENTS 

CHAPTER  PAGE 

IV.    TREATMENT    OF    FRACTURES    OF    THE    MANDIBLE  BY 

THE    METHOD    OF    CL.    MARTIN        -                   -  -       309 

V.    martin's     modes     of     TREATMENT     ACCORDING  TO 

DIFFERENT    TYPES    OF    FRACTURE                   -  '3^5 

VI.    GENERAL     CONCLUSIONS     ON     THE     TREATMENT  0~ 

FRACTURES    OF    THE    LOWER    JAW                   -  -       322 

SECTION  II.— TREATMENT  OF  FRACTURES  OF 
THE  UPPER  JAW 

I.    GENERALITIES  -----  330 

II.    TREATMENT    OF  PARTIAL   ALVEOLAR    FRACTURES       -  332 

III.  TREATMENT    OF  INTERMAXILLARY    DISRUPTIONS       -  S^S 

IV.  TREATMENT  OF  THE    HORIZONTAL  FRACTURE   OF       - 

GUfiRIN     -  -  -  -  -  -334 

V.    TREATMENT    OF    CRANIO-FACIAL    SEVERANCE  -       342 


CLASSIFICATION 

OF  THE  DIFFERENT  METHODS  OF 

RESTORATION  BY  PROSTHESIS 

The  art  of  making  artificial  substitutes  for  any 
organs  cut  off,  whether  by  an  accident  or  by  surgical 
procedures,  constitutes  the  art  of  prosthesis. 

Ambroise  Pare  defined  it  more  succinctly,  in 
writing  that  it  comprised  all  "  methods  and  devices 
for  supplying  that  which,  from  natural  or  accidental 
causes,  is  lacking."* 

The  prosthetic  method  propounded  by  A.  Pare  is 
the  oldest.  It  holds  good  to-da}^;  and  if  in  its  tech- 
nique it  has  risen  to  an  extraordinary  perfection, 
nevertheless  it  still  remains  governed  by  the  same 
general  principles. 

The  advent  of  the  era  of  asepsis  has  allowed  us  to 
think  out  new  prosthetic  methods.  These  are  still, 
at  this  day,  in  full  growth;  none  of  them  has  become 
final,  but  the  unison  which  they  have  called  forth 
between  surgeon  and  prosthesist  promises  fair  to  be 
fertile  of  results.  In  the  vast  majority  of  cases  the 
intervention  of  the  prosthesist   occurs  a  long  time 

*  Ambroise  Pare,  "  CEuvres  completes,"  Lyon,  1646,  23^= 
livre,  p.  572. 

xvii 


xviii         INJURIES  OF  THE  FACE  AND  JAW 

after  that  of  the  surgeon.  Nevertheless  there  are 
instances  where  the  two  procedures  emerge  into  one 
single  operation;  and  from  this  fact  is  derived  a 
division  which  may  serve  as  the  basis  of  a  classifica- 
tion of  the  various  prosthetic  methods. 

These  latter  may  be  drawn  up  into  two  great 
groups : 

External  Prosthesis,  when  we  are  dealing  with 
apparatus  which  remains  in  communication  with 
space. 

Internal  Prosthesis,  when,  allowing  for  the  tolerance 
which  the  tissues,  under  certain  conditions,  display 
towards  foreign  bodies,  {we  make  use  of  apparatus 
which  has  no  communication  with  space.  External 
prosthesis  comprises  remote  and  immediate  pros- 
thesis. 

External  Prosthesis. 

1.  Remote  or  Late  Prosthesis  occurs  a  certain  time 
later  than  the  operation  or  accident  which  has  cut 
off  the  organ  which  it  is  proposed  to  replace,  when 
the  wound  which  was  the  outcome  is  entirely  cica- 
trized. This  process  of  cicatrization  generally  in- 
volves the  formation  of  contractile  fibrous  bands 
which  resist  the  application  of  a  prosthetic  apparatus. 
The  reduction  of  the  vicious  scars  constitutes  the 
first  step  in  any  attempt  at  prosthetic  restoration. 

Thus,  the  study  of  remote  prosthesis  includes  the 
study  of  (i)  methods  for  reducing  scar  tissue,  (2)  re- 
mote prosthetic  methods  proper. 

2.  Immediate  Prosthesis  has  as  its  object  the  pre- 
vention, at  the  outset,  of  cicatricial  contraction  by 


RESTORATION  BY  PROSTHESIS  '  xix 

the  introduction  into  the  tissues  of  an  apparatus 
intended  to  replace  the  part  of  the  skeleton  which 
has  been  removed.  This  apparatus  is  essentially 
temporary;  when,  thanks  to  it,  a  correct  healing  has 
been  obtained,  it  should  be  removed  and  give  place 
to  an  apparatus  which  is  late,  final,  and  re- 
movable. 

Another  plan  of  immediate  prosthesis  consists  in 
introducing  into  the  depth  of  the  tissues  apparatus 
intended  as  a  temporary  substitute  for  part  of 
the  skeleton  after  subperiosteal  resection.  This  ap- 
paratus acts  as  a  prop  for  periosteal  flaps  until  these 
latter  have  given  rise  to  an  adequate  regeneration  of 
bone. 

Thus,  immediate  prosthesis  comprises  two  methods 
quite  distinct : 

{a)  Immediate  prosthesis  intended  to  resist  cica- 
tricial contraction  (CI.  Martin). 

(6)  Immediate  prosthesis  intended  to  hold  up  peri- 
osteal flaps  after  subperiosteal  resection  (Michaels). 

Internal  Prosthesis. 

Internal  Prosthesis  is  designed  to  replace  pieces  of 
bony  framework,  or  certain  organs,  by  means  of 
apparatus  buried  (in  a  final  sense)  in  the  depth  of 
living  tissues.     It  comprises  two  methods: 

I.  Internal  prosthesis  intended  to  guide  bony 
regeneration.  This  regeneration  may  occur  because 
the  resection  was  subperiosteal,  or  it  may  originate 
from  a  bone  graft.  In  this  case,  contrary  to  what 
occurred   in   the   above   method — supra,    2    {h) — the 


XX      ■        INIURIES  OF  THE  FACE  AND  JAW 

i 

prop  for  the  osseous  formation  is  finally  left  in  the   I 
organism.  1 

2.  Internal  prosthesis  properly  so  called,  consisting 
of  an  apparatus  buried  in  the  tissues  and  intended 
to  be  tolerated  there  permanently,  wholly  replacing 
in  function  the  absent  organ. 

.  In  relation  to  the  surgical  procedures  first  taken, 
internal  prosthesis  falls  into  the  subdivisions  of 
immediate  and  remote  prosthesis. 

Such  are  the  divisions  which  it  seems  to  us  logical 
to  introduce  into  the  study  of  the  various  prosthetic 
methods  which  we  propose  to  examine  according  to 
this  classification. 

We  are,  as  a  matter  of  fact,  not  discussing  certain 
varieties  of  late  prosthesis  which  are  of  interest  to 
commercial  circles.  Internal  prosthesis  by  injections 
of  paraffin  is  a  restoratory  method  which,  since  it 
does  not  belong  to  the  dental  speciality,  we  shall 
remove  from  our  scheme  of  study. 

Let  us,  then,  resume  in  the  following  way  the 
classification  of  existing  prosthetic  methods.* 

*  For  everything  concerning  dental  prosthesis,  properly 
so  called,  the  reader  can  refer  to  the  "  Manuel  de  Clinique  de 
Prothese  dentaire  "  of  P.  Martinier  and  G.  Villain. 


Injuries  of  the  Face  and  Jaw 
and  their  Repair 

FIRST  PART 
EXTERNAL    PROSTHESIS 

SECTION  I 

REMOTE   PROSTHESIS 

This  is  the  oldest  method.  The  type  of  this  which 
is  the  simplest,  and  which,  moreover,  seems  never 
to  have  emerged  from  the  province  of  orthopaedic 
and  surgical  instrument  makers,  is  the  artificial  limb 
fitted  to  a  stump  after  an  amputation.  But,  as 
applied  to  losses  of  tissue  involving  the  face,  remote 
prosthesis  demands  a  special  technique.  This  is 
connected  with  the  technique  of  dental  prosthesis, 
was  evolved  by  dentists,  and  belongs  exclusively  to 
their  department.  Remote  prosthesis  of  the  lower 
jaw  in  particular  constitutes  a  problem  of  singular 
complexity.  In  fact,  after  the  removal  of  a  part  of 
the  lower  jaw,  cicatricial  contraction  involves  such 
extensive  displacements  that,  until  these  latter  have 
been  reduced,  one  must  not  dream  of  making  a 
prosthetic  apparatus. 


INJURIES  OF  THE  FACE  AND  JAW 


O 
I— I 

H 

< 

O 
H 

W 


H 
W 

en 
O 

PL. 


o  o 


n3  ^ 
p    o 


03  +j 


C^'i<   C 


rt 


o  .^ 


-^.2 


o 
o 
o 


u  o  o 


o  --^  >; 


C!.t= 


> 

c 


c3   rt 


tfJ     t/3 


^   C    - 


■  i:  o  o  o 
u<  v<   w 


.ii  a;  ^  rf 

Sa  ■"  "o  "" 
Ch  . .        5>- 

•^  o  rt 
><  o 

4>  -H 


O 


C4 


to  


C^ 


< 
OS 

w 

H 


0   g^   3 

fe  £ 

ac^ 

0  . 

M-.   .is            4-> 

•-  "^  ,/■■ 

;2  ri  ti  c3 

c  c  i: 

s 

0  ^  J? 

•^ 

0  ..-■  ■'^     TO 

-^7^ 

Vh     0            ti 

(U    ^     c3 

•^  r!  n^  0, 

>, 


O    >^   2- 
g3  eye 


v-  O  P 

■>^^ 

O  4J  •'^ 

UH      TO 


01 


O 


o     . 
o 


-t-) 

oi 

>-• 

rt 

ac 

P-  0 

<A 

.r-t 

nJ 

rt 

0 

C 

-i-> 

r/1 

^ 

0 

CHARACTER  OF  CICATRICIAL  TISSUE  3 

Remote  prosthesis  of  the  face  often  falls  into 
clearly  cut  steps: 

1.  Stage  of  reduction  of  scar  tissue. 

2.  Stage  of  prosthesis  proper. 

Dentists,  well  prepared  for  this  task  by  their 
familiarity  with  the  general  principles  of  orthodontia 
which  they  apply  every  day,  have  managed  to  excel 
in  this  method  of  bucco-facial  prosthetic  restoration. 


CHAPTER  I 

CHARACTER  OF  CICATRICIAL  TISSUE 

The  term  "cicatrization"  is  given  to  the  organic 
process  tending  to  the  production  of  a  new  tissue 
destined  to  close  accidental  or  surgical  solutions  of 
continuity  produced  in  the  body.  This  tissue  formed 
in  this  way  is  called  a  "  cicatrix." 

The  histological  elements  of  a  scar  arise  from  the 
proliferation  of  histological  elements  which  were 
there  previously,  and  the  two  are  always  similar. 
The  repair  is  usually  provided  by  the  connective 
tissue,  but  in  the  case  of  skin  and  mucous  membranes 
epithelial  tissue  shares  in  the  constitution  of  the 
cicatrix. 

We  will  consider  cicatrization  by  first  and  by 
second  intention. 

"  Although  the  essential  phenomena  in  the  two 
cases  are  identical,  the  intervention  of  a  new  factor, 
suppuration,  gives  to  the  cicatrization  of  an  infected 
wound  some  special  characteristics."* 

*  Francisque  Martin,  "  Bloodless  Treatment  of  Vicious 
Scars,"  These  de  Lyon,  1901. 


4  INJURIES  OF  THE  FACE  AND  JAW 

I.  Cicatrization  by  First  Intention. — When  the  hps 
of  the  wound  are  approximated,  they  are  soon  glued 
together,  first  by  the  blood  poured  out,  later  by 
serum  which,  exuded  from  neighbouring  vessels, 
contains  embryonic  connective-tissue  cells.  This 
embryonic  tissue  is  soon  invaded  by  newly  formed 
capillaries.  According  to  Masse,*  "  The  vessels  of 
neighbouring  parts  of  the  new  scar  tissue  produced 
show  at  first,  at  one  point  of  their  walls,  some  tiny 
bosses,  which  become  changed  into  little  processes, 
pointed  at  their  end  and  enlarged  at  their  base. 

"The  parent  vessel  is  usually  a  capillary  with  struc- 
tureless walls,  with  some  fusiform  cells  at  regular 
intervals.  The  new  vessels  which  are  produced  are 
of  the  same  nature ;  tapering  in  shape,  their  walls  are 
hyaline,  the  cells  more  numerous  and  especially  more 
crowded.  At  first  of  a  very  small  calibre,  they  can- 
not allow  of  the  passage  of  corpuscles;  only  the 
blood-plasma  can  course  through  them.  These 
tapering  vessels  become  more  and  more  prominent 
in  the  cicatricial  tissue.  Their  increase  in  height 
goes  hand  in  hand  with  an  increase  in  width;  mean- 
while they  anastomose  one  with  the  other,  and  form 
loops  which  are  at  first  permeable  only  to  the  plasma, 
later  to  blood-corpuscles.  The  first-formed  loops 
soon  give  rise  to  other  pointed  branches,  which  in 
turn  join  to  form  secondar}^  loops;  then  a  third,  and 
so  on." 

The  capillaries  emerging  from  one  lip  of  the  wound 
meet  those  of  the  opposite  lip,  and  form  an  anasto- 

*  Masse,  "  Cicatrization  in  Different  Tissues,"  Montpellier, 
1866. 


CHARACTER  OF  CICATRICIAL   TISSUE  5 

mosis  which  re-estabUshes  the  circulation  from  one 
edge  of  the  wound  to  the  other. 

These  embryonic  vessels  take  on  progressively  the 
characters  of  adult  vessels;  the  same  applies  to  the 
embryonic  cells,  which  become  adult  connective- 
tissue  cells.  Later  the  cicatrix  undergoes  further 
modification,  and  at  the  end  of  its  evolution  it  will 
consist  of  fibrous  tissue. 

2.  Cicatrization  by  Second  Intention. — When  the 
lips  of  a  wound  have  not  been  approximated,  cica- 
trization is  produced  by  means  of  a  layer  of  fleshy 
buds  covering  the  bottom  of  the  wound.  These 
fleshy  buds  form  the  granulation  layer,  of  which  the 
characters  have  been  carefully  described  by  the  old- 
time  surgeons.  In  fact,  they  represent  the  method 
of  cicatrization  natural  to  all  infected  wounds. 

It  is  on  the  surface  of  this  granulation  layer  that 
the  secretions  are  produced  which  constitute  pus. 
This  very  surface  is  absorbent,  witness  the  poisoning 
by  sprinkling  ulcerations  with  iodoform.  Lastly,  these 
fleshy  buds  have  a  power  of  contraction  which 
gradually  approximates  the  edges  of  the  wound. 

"  This  approximation  occurs  especially  when  the 
wound  is  cleansed.  At  this  time  one  observes  the 
occurrence  of  a  series  of  changes  at  the  surface. 
The  suppuration  dries  up,  the  fleshy  buds  take  on  a 
rich  red  colour,  the  edges  of  the  wound  contract  and 
approach  each  other  under  the  influence  of  the  con- 
traction of  the  granular  layer.  On  these  edges 
appears  a  bluish  border,  originating  in  the  healthy 
surrounding  skin.  This  border  approaches  little  by 
little  the  centre  of  the  solution  of  continuity,   the 


6  INJURIES  OF  THE  FACE  AND  JAW 

surface  of  which  it  gradually  diminishes.  This  japan 
or  varnish  of  epidermis  gains  ground  from  the  peri- 
phery towards  the  centre  incessantly,  and  soon  the 
surface  of  the  buds  is  epithelialized.  The  cicatriza- 
tion of  the  wound  is  complete. 

"  In  certain  cases,  the  slight  exudate  which  a  wound 
in  the  process  of  cicatrization  incessantly  secretes 
hardens  on  the  surface,  and  covers  it  with  a  dry  scab, 
beneath  which  epithelialization  proceeds  just  as 
when  exposed  to  the  air.  This  mode  of  healing,  of 
which  it  has  been  proposed  to  make  a  separate  variety 
termed  '  cicatrization  beneath  a  scab,'  differs  in 
no  way  in  nature  from  cicatrization  by  second  in- 
tention."* 

The  granulation  layer  to  which  we  just  now  referred 
is  a  soft  tissue  composed  of  round  cells.  Among 
these,  certain  cells  are  multinuclear;  they  are  destined 
to  die  and  form  pus.  In  the  neighbourhood  of  these 
multinuclear  cells,  which  will  be  destroyed,  are  found 
numerous  mononuclear  cells,  of  which  some  are  large 
and  resemble  epithelial  cells.  It  is  these  epithelioid 
cells,  according  to  Ziegler,t  which  give  rise  to  granu- 
lation tissue.  They  are  called  "fibroblasts"  or 
"  fibroblastic  cells,"  because  they  have  the  power  of 
forming  connective  tissue. 

"The  fibroblasts  of  most  recent  origin  occur  as 
round  cells,  but  their  shape  is  altered  very  soon; 
they   put    out    processes    which    become    gradually 

*  Francisque  Martin,  "  Bloodless  Treatment  of  Vicious 
Scars,"  These  de  Lyon,  1901. 

f  Ziegler,  "  Treatise  of  Pathological  Anatomy,"  translated 
by  Augier  and  Von  Ermengen,  1892. 


CHARACTER  OF  CICATRICIAL  TISSUE  7 

lengthened.  Thus  cells  are  formed,  some  club- 
shaped,  some  fusiform;  others,  again,  branched  and 
united  very  irregularly  by  their  branches.  At  the 
same  time  the  number  of  large  formative  cells  in- 
creases in  such  wise  that  at  last  they  get  the  better 
of  their  small  round  neighbours,  and  group  them- 
selves here  and  there  in  crowded  masses;  this  occurs 
especially  in  the  deeper  parts  of  the  fleshy  buds. 

"  A  sufficient  massing  together  of  the  formative 
cells  inaugurates  the  development  of  the  connective 
tissue,  or  intermediary  fibrous  tissue.  This  latter  is 
formed  partly  at  the  immediate  expense  of  the  proto- 
plasm of  the  formative  cells,  partly  at  the  expense  of 
the  homogeneous  matrix,  which,  again,  has  previously 
been  formed  by  the  fibroblasts  or  formative  cells. 

"  In  the  former  case  [where  the  connective  tissue 
is  formed  at  the  direct  expense  of  the  cell  proto- 
plasm— Tr.]  one  can  note  the  appearance,  on  the 
sides  as  well  as  at  the  ends  of  the  formative  cells, 
of  fine  fibrillar  processes  arising  from  neighbouring 
cells.  The  direction  and  mass  of  the  bundles  thus 
formed  are  independent  of  the  original  shape  and 
situation  of  the  cells  which  gave  them  origin ;  usually 
the  direction  of  the  bundles  is  that  of  the  greater 
diameter  of  these  cells.  When  a  sufficient  number 
of  fibrils  has  been  produced,  their  formation  ceases. 
The  remains  of  nucleated  protoplasm  in  the  original 
cells  become  the  fixed  cells  of  the  connective  tissue, 
which  remain  attached  to  the  surface  of  the  bundles 
of  fibrils.  It  is  thus  that  the  process  comes  to  an 
end,  and  granulation  tissue  becomes  a  cicatrix."* 

*  Francisque  Martin,  "  Bloadless  Tie.itmon':  of  tjVicious 
Scars,"  These  de  Lyon,  1901. 


8  INJURIES  OF  THE  FACE  AND  JAW 

3.  Epithelialization. — The  newly  formed  epithelium 
which  covers  the  superficial  stratum  of  fleshy  buds 
never  arises  from  these;  it  is  always  traceable  to 
neighbouring  epidermal  cells.  This  epithelialization 
can  take  place  in  three  ways : 

{a)  By  sliding  of  epithelial  cells  from  the  periphery 
towards  the  centre. 

{b)  By  grafting  of  epithelial  islands  detached  from 
the  edges. 

(c)  By  cellular  proliferation  along  the  edges  of 
the  wound,  thus  tending  to  a  progressive  centripetal 
epithelialization. 

When  the  cicatrix  is  fully  formed,  it  undergoes  an 
evolution  which  may  last  from  eighteen  months  to 
two  years,*  and  during  which  the  new  tissue  of  which 
it  is  formed  sufiers  a  series  of  changes.  This  cicatrix, 
now  adult,  will  contain  fibrous  tissue  and  show  a 
new  structure  and  new  physical  properties. 

According  to  Francisque  Martin,  if  one  dissects 
and  carefully  examines  a  fully  formed  scar,  one  sees 
that  it  consists  of — 

1.  A  thin  superficial  membrane,  sometimes  rugous, 
more  usually  uniform  and  glossy;  this,  which  is  the 
newly  formed  epidermis,  is  dry,  because  no  secretion 
appears  to  moisten  it. 

2.  Deep  to  this  epidermis  is  a  special  sort  of  tissue, 
of  fibrous  appearance,  dense,  resistant,  pearly  white, 
creaking  under  the  scalpel.  This  is  the  fundamental 
part  of  the  scar,  or  "  inodular  "  tissue,  which  results 
from  the  cicatrization  of  the  dermis. 

3.  In    this    dense    non-porous    tissue    are    formed 

*  Dupuytren,  "  Cliniques  Chirurgicales,"  iv. 


CHARACTER  OF  CICATRICIAL  TISSUE  g 

arterioles  and  venules  in  very  small  number  and 
tightly  bound  down.  "  Inodular  "  tissue  constitutes 
the  fundamental  element  of  adult  scar  tissue.  Delpech 
has  given  it  this  name  in  contradistinction  to  young 
cicatricial  tissue,  which  is,  on  the  other  hand, 
"  nodular  "  tissue. 

"  In  the  skin,  a  cicatrix  consists  of  fibrous  tissue, 
where  fat -vesicles  soon  appear  in  the  deep  layers; 
but  there  are  never  as  many  fat-vesicles  as  in  the 
normal  condition,  and  the  fibrous  tissue  found  is 
always  very  dense.  The  dermis  is  produced  in 
fibrous  and  elastic  tissue,  but  glands  are  not  repro- 
duced. The  papillae  are  re-formed  in  the  cases  where 
they  had,  by  their  hypertrophy,  made  up  the  fleshy 
buds  of  the  cicatricial  tissue.  In  such  a  case  the 
normal  papillae  of  the  skin,  transformed  into  fleshy 
buds,  return  to  their  primitive  condition;  then  some 
of  the  buds  sink  down,  and  the  embryonic  tissue 
becomes  connective  tissue. 

"  But  when  the  fleshy  buds  spring  up  from  the 
deeper  parts,  and  the  papillae  have  been  destroyed 
to  a  marked  extent,  they  do  not  become  entirely 
re-formed;  and  the  cutaneous  scar  which  results 
remains  flat  and  depressed,  or,  on  the  other  hand, 
prominent,  if  the  exuberant  granulations  have  not 
been  restrained.*  Our  knowledge  of  the  structure 
of  the  retractile  scars  which  follow  on  union  by 
second  intention  is  less  exact.  On  this  point  Fran- 
cisque  Martin  quotes  in  his  thesis  the  following 
interesting  remark  of  Paviot :  '  It  is  easy  to  demon- 
strate  that    in   the   depth   of   connective   tissue   in 

*  Cornil  et  Ranvier,  "  Manuel  d' Histologic." 


lo  INJURIES  OF  THE  FACE  AND  JAW 

general  elastic  fibres  and  elastic  granules  are  very 
rare  if  the  tissue  be  a  young  one  containing  many 
round  cells.  And,  on  the  other  hand,  when  the 
number  of  round  cells  is  less,  when  the  connective- 
tissue  fibres,  increasingly  full-grown  and  thick,  appear 
in  a  similar  kind  of  tissue,  the  elastic  fibres  and 
granules  (as  to  the  origin  of  which  no  one  has  been 
able  to  lay  down  anything  beyond  theories)  increase 
proportionately  in  number.  This  is  demonstrated 
daily  by  all  histologists ;  but  the  role  of  these  elastic 
fibres,  under  the  circumstances  which  we  are  study- 
ing, has  never  been  laid  down  accurately.' 

"  May  we  not  suppose  that  it  is  to  the  trans- 
formation of  the  tissue  to  the  inodular  type,  when 
the  elastic  elements  appear,  that  a  cicatrix  owes  the 
loss  of  its  retractility  ?  Perhaps  one  may  also  infer 
that  the  extensibility  of  an  inodular  scar  depends  on 
the  presence  of  the  elastic  elements.  In  support  of 
the  probable  truth  of  this  argument,  one  may  cite 
a  histological  contrast  easy  to  make,  between  a 
keloid  scar  which  is  still  to  a  large  extent  nodular, 
and  a  linear  fibrous  scar  robbed  of  all  round  cells  and 
already  rich  in  elastic  elements." 

4.  Physical  Characters  of  Cicatricial  Tissue. — When 
it  has  lost  its  suppleness,  cicatricial  tissue  possesses 
a  good  deal  of  toughness;  its  elasticity  is  nil,  but  it 
is  noticeably  extensible  and  capable  of  elongation 
under  a  slow  and  continuous  pressure.  It  has  no 
real  retractility.  Minervini*  has  shown  experi- 
mentally that  only  the  cellular  tissue  of  a  cicatrix 

*  Minervini,  "  On  the  Retractile  Power  of  Cutaneous 
Scars"  (13'^  Congres  Internat.  de  Medecine,  Paris,   1910). 


CHARACTER  OF  CICATRICIAL  TISSUE  ii 

is  retractile.  A  scar,  once  formed,  does  not  retract. 
"  Thus,  we  should  speak,  not  of  a  retractile  cicatrix, 
but  of  cicatricial  retraction."*  Francisque  Martin 
thinks  that  the  retractility  of  a  cicatrix  undergoing 
evolution  depends  upon  the  inflammatory  process 
which  accompanies  cicatrization,  and  according  to 
him  there  is  a  correlation  between  the  duration  of 
suppuration  and  the  retractile  power  of  a  scar. 

A  scar  fully  formed  may  be  made  supple  and 
lengthened  when  it  is  made  to  undergo  long  and 
continuous  pressure.  "  This  relaxation  and  length- 
ening of  scars  is  not  invariable  unless  certain  nutri- 
tional changes  occur.  But  the  exact  nature  of  these 
changes,  clinically  obvious,  are  not  known  to  us; 
and  to  arrive  at  final  conclusions  on  this  point  a 
series  of  histological  examinations  bearing  on  scars 
before  and  after  their  lengthening  will  be  required. "f 
Be  this  property  what  it  may,  it  is  thanks  to  it  that 
vicious  cicatrices  may  be  corrected  by  the  help  of 
prosthetic  treatment.  In  fact,  consequent  upon  a 
prolonged  suppuration,  the  scarring  of  a  wound  often 
produces  bands  and  adhesions  more  or  less  extensive, 
which  in  turn  entail  a  varying  degree  of  functional 
incapacity  of  the  affected  part.  These  vicious  scars 
necessitate  surgical  intervention,  of  which  the  results 
are  often  unreliable.  Side  by  side  with  the  surgical 
treatment,  on  the  other  hand,  the  bloodless  treat- 
ment of  the  scars  by  prosthesis  should  have  a  place. 

♦  Francisque    INIartin,    "  Bloodless    Treatment    of    Vicious 
Scars,"  These  de  Lyon,  1901. 
t   Ibid. 


12  INJURIES  OF  THE  FACE  AND  JAW 


CHAPTER  II 

THE  BLOODLESS  TREATMENT   OF   VICIOUS 

SCARS 

The  bloodless  treatment  of  vicious  scars  is  wholly 
due  to  CI.  Martin  of  Lyons.  In  1900  he  laid  down 
the  general  principles  of  his  method,  as  follows: 

"All  patients  on  whom  any  part  of  the  lower  jaw 
has  been  resected,  and  to  whom  an  immediate 
prosthesis  has  either  not  been  applied  or  has  remained 
an  insufficient  time,  are  as  a  rule  invalids.  The 
aesthetic  changes  and  the  functional  troubles  which 
they  have  to  endure  depend  on  one  and  the  same 
cause — that  is,  the  projection  inwards  of  one  or  more 
bony  fragments.  These  troubles  comprise  facial 
asymmetry,  the  sagging  of  skin  not  supported  by 
a  bony  plate,  the  atresia  of  the  mouth  or  forward 
projection  of  the  tongue  and  the  flow  of  saliva  out- 
side, the  lack  of  apposition  of  the  dental  arches, 
and  the  difficulties  in  mastication  which  result  there- 
from. In  the  presence  of  such  infirmities,  I  have 
asked  myself  if  it  is  not  possible  to  alleviate  these 
patients.  And  therefore  I  have  sought  to  correct 
the  underlying  lesion,  on  which  the  other  evils  depend 
— that  is,  the  cicatricial  retraction  which  produces 
the  deviation  of  the  bony  fragments  and  the  flatten- 
ing of  the  cheek  on  the  side  operated  on. 

"  In  my  earlier  researches  I  had  established  an 
arrangement  of  apparatus  which  allows  one  to  drag 
the  bony  extensions  to  their  normal  positions  and 
keep  them  there,  all  the  while  leaving  them  free  to 


BLOODLESS  TREAT  MENT  OF  VICIOUS  SCARS     13 

resume  their  functions.  But,  despite  this  correction, 
I  had  never  been  able  to  restore  the  buccal  cavity  to 
its  original  dimensions.  I  had,  in  fact,  constantly  to 
combat  this  unceasing  and  considerable  force — the 
cicatricial  retraction,  which  perpetually  tends  to  spoil 
the  result  obtained. 

"  These  comparative  failures  had  made  it  clear  to 
me  that  I  should  not  be  able  to  achieve  any  unalter- 
able result  without  dealing  with  the  scar  itself. 
Thus,  I  have  striven  to  alter  it,  to  soften  it,  to  make 
it  extensible — in  a  word,  to  stretch  it  in  such  wise 
that  the  fragments  could  occupy  their  former  position. 

"  I  have  achieved  this  result  by  means  of  special 
apparatus  to  which  I  have  given  the  name  of 
heavy  appliances  or  appliances  for  continuous  pres- 
sure. The  application  of  the  method  which  I 
have  just  shown  is  not  limited  to  the  correction 
of  deformities  due  to  scars  after  resection  of  the 
jaw;  it  is  a  more  general  plan  to  which  all  de- 
formities due  to  scar  tissue  are  amenable.  The 
essential  principles  are  frequent  massage  and  con- 
tinuous pressure  applied  to  the  inodular  tissue.  But 
if,  for  resections  of  the  jaw,  the  position  of  parts 
allows  us  to  take  advantage  of  gravity,  this  does  not 
apply  for  other  scars — for  example,  on  the  neck. 
One  can  then  obtain  continuous  pressure  by  means 
of  elastic  traction  apparatus,  of  which  one  can  at  will 
graduate  the  pressure."* 

"  To  sum  up,   the   fundamental  principle  of  the 

*  Cl.  Martin,  "  Methods  of  correcting  Deformities  due  to 
Vicious  Scars  by  Heavy  Appliances  or  Appliances  for  Con- 
tinuous Pressure"  (Cong,  de  Chir.,  Paris,  1900). 


14  INJURIES  OF  THE  FACE  A  ND  JAW 

method  which  we  advocate  is  the  following:  Bring 
to  bear  on  the  cicatricial  tissue  a  slow  and  continuous 
action,  which  will  coax  it  in  the  direction  opposite 
to  that  of  its  retractility,  and  which  can  undo  what 
this  retractile  force  has  done."* 

The  means  to  which  one  can  resort  differ  according 
to  the  form  of  the  scar  and  the  region  affected. 
Annular  scars  can  be  stretched  either  by  means  of 
apparatus  of  soft  elastic  rubber  or  by  spring  ap- 
paratus. Linear  scars  may  be  stretched  by  con- 
tinuous pressure  of  heavy  appliances  or  under  the 
influence  of  traction  apparatus.  Traction  and  pres- 
sure are  all  the  means  generally  used,  whether  we 
adopt  heavy  appliances,  or  elastic  force  as  shown 
in  the  well-known  plan  of  Fr.  Martin  (Figs,  i  and  2). 

But  the  mechanical  treatment  of  vicious  scars  is 
governed  by  the  following  general  rule :  The  reduction 
apparatus  should  act  on  the  scars  very  gently,  and 
never  cause  the  patient  the  least  pain.  These  appli- 
ances are  as  various  as  the  deformities  which  they 
are  destined  to  correct;  so  we  shall  limit  ourselves, 
in  this  book,  to  describe  only  those  which  have  been 
employed  most  often  by  CI.  Martin  at  the  level  of  the 
jaws. 

I.  Upper  Jaw. 

Resections  of  the  maxilla  often  cause  but  little 
deformity  in  the  region  of  the  face.  Nevertheless, 
the  soft  parts  of  the  cheek  may  form  deep  adhesions 
which   become   irksome   for   the    application   of    an 

*  Fr.  Martin,  "  Bloodless  Treatment  of  Vicious  Scars," 
These  de  Lyon,  igoi. 


BLOODLESS  TREATMENT  OF  VICIOUS  SCARS     15 

appliance  for  remote  prosthesis.     In  such  cases  CI. 
Martin  has  used  the  following  apparatus: 

A  palatine  piece  covers  the  roof  of  the  mouth, 
including  the  loss  of  substance  left  by  the  surgical 
intervention.  It  is  fixed  to  the.  teeth  of  the  left 
maxilla,  and  on  the  right  it  is  kept  up,  supported 


Figs,   i  and  2. — Traction  Apparatus  of  Fr.  Martin. 

by  a  spring  taking  its  point  d'appui  from  the  lower 
jaw,  like  a  denture.  This  principal  piece  bears  two 
other  accessory  pieces.  One  is  fixed  without  a  joint 
on  its  upper  surface  near  its  posterior  edge,  and 
passes  up  to  the  top  of  the  cavity  to  fit  which  it  has 
been  cast.     The  other  is  attached  to  the  front  part 


i6 


INJURIES  OF  THE  FACE  AND  JAW 


of  the  Upper  surface,  by  a  hinge  joint  placed  a  httle 
lower  than  the  anterior  border  of  the  cavity.  A 
spring  placed  horizontally  on  the  former  (posterior) 
of  these  accessory  pieces  plays  on  to  the  latter 
(anterior),  which  moves  like  a  hinged  shutter.  This 
spring  by  its  continuous  pressure  on  the  scar  tissue 
gradually  stretches  it  (Fig.  3).* 

We  may  equally  well  apply  to  the  maxilla  the 


Fig.   3. ^Apparatus  for  stretching  after  Resection  of  the 
Maxilla.     (CI.  Martin.) 

pressure  produced  in  mastication,  by  fitting  an 
apparatus  of  gradually  increasing  volume  at  the  level 
of  the  scar  tissue  to  be  stretched. 

One  of  usf  has  used  this  plan  successfully  on  a 
patient  who  had  undergone  resection  of  the  left 
upper  jaw.  It  was  expedient,  before  fixing  a  final 
prosthesis  on   this  patient,  to   force  back  the  scar 

*  CI.  Martin,  "  jNIethods  of  correcting  Deformities  due  to 
Vicious  Scars  by  Heavy  Appliances  or  Appliances  for  Con- 
tinuous Pressure  "  (Cong,  de  Chir.,  Paris,  1900). 

f  Martinier,  "  Two  Typical  Cases  of  Restoration  of  the 
Maxillae"  {Odontologie,  15  Mars,  1903,  p.  225). 


Fig.  4. — :\Iodel  in  Plaster  Cast  of  the  First  Impression.  To 
the  right  of  the  figure,  the  perforation  which  makes  the 
mouth  communicate  with  the  antrum  and  nasal  fossae. 
(Martinier.) 


Fig.  5. — Model  in  Plaster  Cast  of  the  Last  Impression,' after 
the  Cicatrization  of  the  Soft  Parts  and  the  Dilatation  of 
the  Scar  Tissue.      (Martinier.) 

2 


i8 


INJURIES  OF  THE  FACE  AND  JAW 


tissue  which,  in  producing  the  classical  deformities 
consecutive  to  total  ablation  of  the  maxilla,  had 
invaded  the  operation  cavity.  The  treatment  is  as 
follows:  The  plaster  mould  of  the  remaining  moiety 
of  the  maxilla  is  taken,  as  well  as  of  the  mandible, 
and  to  initiate  the  slow  stretching  of  the  cicatricial 
bands  one  makes  a  provisional  correcting  appliance 
consisting  of  a  metal  framework  composed  thus: 


Fig 


6. — The  First  or  Provisional  Appliance  seen  from  its 
Upper  Aspect.  To  the  right  of  the  figure  the  original 
skeletal  part,  to  the  left  of  the  figure  the  part  made  of 
hard  rubber  destined  to  cover  the  palatal  vault  and 
close  in  the  perforation.  The  outer  part  of  the  appliance 
may  be  fitted  with  a  bed  of  gutta-percha  to  increase  its 


1.  An  external  band  encircling  the  dental  arch  and 
fitting  the  gum. 

2.  A  beaten  plate  on  what  remain*  of  the  palate, 
to  which  are  soldered  metal  prolongations  intended 
to  give  support  to  a  piece  of  vulcanized  rubber. 
This  piece,  forming  a  bridge  above  the  hole  in  the 


BLOODLESS  TREATMENT  OF   VICIOUS    SCARS     19 

palate,  is  an  exact  replica  of  a  block  of  wax  which 
has  previously  been  fixed  to  the  prolongations  and 
tried  in  the  mouth,  with  the  idea  of  moulding  the 


h?. ^^.^ 


Fig.  7. — The    Same    Appliance:  Lateral    View    of    Anterior 
Surface.     The  white  part  shows  the  added  gutta-percha . 

scar  tissue  of  that  region  which  the   apparatus  is 
meant  to  stretch  (Figs.  4  to  10). 


Fig.  8. — The  First  or  Provisional  AppHance,  Lower  Surface, 
with  its  Articulating  Edge  which  will  hnk  up  the  Two 
Jaws. 

It   has  on  its  lower  part   an  articulating  border 
destined    to    re-establish    the    relations    of    the    two 


20 


INJURIES  OF  THE  FACE  AND  JAW 


jaws  in  the  movements  of  occlusion  and  articulation 
(Fig.  8). 
The  external  band  and  palatine  plate  are  joined 


Fig.  9. — The  Same:  Lateral  View  of  Anterior  Surface. 

one  to  the  other  by  a  series  of  hooks  of  platinized 
gold  applied  to  the  internal  and  external  aspects  of 
the   teeth,    and   soldered   only   on   the   central   side 


^-4\j^Mii5»*5>^ 


Fig.   10. — The    Second    Apphance    with    its    Final    Metallic 
Skeletal  Part,  External  Wing,  and  Special  Hooks. 

through  a  very  small  part  of  their  extent,  so  as  to 
give  them  a  very  great  elasticity  (Fig.  10). 

The  volume  of  the  whole  is  increased  by  applying 
gutta-percha.  If  it  be  desired,  one  can  eschew  the 
use  of  gutta-percha,  which  has  the  disadvantage  of. 


BLOODLESS  TREATMENT  OF   VICIOUS  SCARS     21 

gradually  softening  in  the  mouth.  The  process 
consists  in  vulcanizing,  at  the  time  of  making  the 
apparatus,  a  series  of  small  rubber  plates,  taking  the 
external  shape  of  the  appliance  at  that  part  intended 
to  stretch  the  cicatricial  tissues.  The  superposition, 
one  after  the  other,  of  the  small  plates  in  this  way 
increases  the  pressure  on  the  tissues  to  be  stretched. 


Fig.    II. — Lower  Lingual  Aspect  of  Final  Appliance. 


These  small  plates  may  be  fixed  to  the  appliance  by 
screws.  One  will  take  care  beforehand  to  prevent 
the  saliva  soaking  in,  by  plastering  the  inner  side  of 
the  platelet  and  the  corresponding  part  of  the  appli- 
ance with  a  solution  of  rubber  in  chloroform.  Having 
obtained  complete  dilatation  of  the  cicatricial  mass, 
it  only  remains  to  make  a  final  appliance  carrying 


22  INJURIES  OF  THE  FACE  AND  JAW 

teeth  articulating  with  those  of  the  lower  jaw.  The 
arrangement  with  hooks  which  we  have  just  described 
constitutes,  in  our  opinion,  the  method  of  choice  for 
fixing  this  sort  of  apparatus.  The  springs  so  con- 
stantly employed  are  very  irksome  to  the  patient, 
besides  which,  applied  as  they  are  and  placed  in 
contact  with  the  surrounding  tissues,  they  cannot  fail 
to  irritate  these  and  retard  a  favourable  result. 

At  this  stage  certain  considerations  crop  up  on 
which  we  shall  enlarge  later.  In  a  general  way,  it 
may  be  said  that  the  primary  apparatus  to  restore 
large  losses  of  substance  in  the  region  of  the  upper 
jaw  should  be  the  lightest  possible  (hollow  apparatus), 
to  facilitate  their  retention. 

The  same  does  not  apply  round  about  the  lower 
jaw,  where,  on  the  contrary,  heavy  apparatus  are 
indicated  for  the  same  reason. 


II.  Lower  Jaw. 

• 

The  partial  or  total  resections  of  the  horizontal 
ramus  of  the  lower  jaw  produce  cicatricial  deformities 
and  displacements  from  contraction,  which  in  most 
cases  entail  serious  functional  disabilities. 

Following  on  a  partial  resection  of  the  jaw,  one 
notices,  in  fact,  that  the  cicatricial  tissue  forms  a 
linear  band  between  the  ends  of  the  two  bones,  and 
carries  the  remaining  fragments  inwards  and  back- 
wards. Mastication  is  impossible,  since  the  teeth 
no  longer  articulate ;  the  Hps,  lacking  the  support  of 
the  skeleton,  allow  the  saliva  to  trickle  out. 

For  a  long  while  we  have  sought  to  remedy  these 


BLOODLESS    TREATMENT  OF   VICIOUS  SCARS     23 

serious  troubles  resulting  from  resection  of  the  lower 
jaw.  Mursinna  in  Germany  and  Verhuylen  at 
Antwerp  made  the  first  efforts. 

The  appliance  of  Mursinna  was  an  external  one, 
and  consisted  simply  of  a  sling,  which  hid  the  de- 
formity fairly  well.  A  sponge  placed  inside  absorbed 
the  saliva. 

Verhuylen's  apparatus  replaced  the  whole  jaw; 
it  was  actuated  by  a  spring  which  kept  the  lower 
dental  arch  against  the  upper.  To  use  it,  the  patient 
lowered  with  his  hand  the  chin  band  containing  the 
jaw,  introduced  his  food,  and  released  the  catch. 
Afterwards  Preterre  constructed  divers  appliances 
which  have  alread}^  brought  about  excellent  progress. 

Results  of  Resections  performed  upon  the  Lower 
Jaw. — Following  on  the  resection,  the  jaw  fragments 
become  displaced,  irresistibly  .pulled  by  the  cica- 
tricial retraction  and  the  contraction  of  the  muscles 
there  inserted.  The  dental  arches  no  longer  corre- 
spond, and  their  movements  sideways  are  very 
considerable.  For  instance,  we  often  observe  the 
front  teeth  of  the  left  lower  fragment  articulating 
with  the  upper  right  molar  teeth,  the  upper  left 
teeth  biting  on  the  gums  and  on  the  lower  part  of 
the  left  cheek,  thus  giving  rise  to  ulcerations  in- 
tractable to  all  treatment.  The  cavity  of  the  mouth 
is  narrowed;  the  tongue,  lacking  its  place  in  the 
mouth,  is  projected  forwards.  Under  these  condi- 
tions mastication  is  quite  impossible,  swallowing 
much  hampered,  and  pronunciation  unintelligible. 

Preterre,  who  during  the  Italian  War  had  been 
able    to    observe    these     deformities     in     numerous 


24  INJURIES  OF  THE  FACE  AND  JAW 

cases,  was  anxious  to  remedy  them  so  far  as  possible. 
So  he  waited  until  cicatrization  was  complete,  and 
when  he  judged  the  time  opportune,  because  there 
was  no  more  deformity  to  fear  from  retraction  of 
scar  tissue,  he  took  an  impression  and  applied  his 
apparatus.  This  apparatus  consisted  of  a  second 
artificial  dental  arch  placed  in  front  of  the  natural 
deviated  arch,  which  it  ensheathed,  and  from  which 
it  derived  its  support.  The  artificial  denture  articu- 
lated with  the  teeth  of  the  upper  jaw.  The  patient 
then  had  a  lower  jaw  in  two  tiers,  reminding  one  of 
a  shark's.  Preterre's  appliance  greatly  facilitated 
mastication  by  giving  a  comparatively  sturdy  pomt 
d'appui  to  the  teeth  of  the  upper  jaw,  which  thus 
could  not  impinge  on  the  lower  lips.  But  by  its 
volume  it  still  further  narrows  the  buccal  cavity, 
the  tongue  is  still  more  cramped  than  before,  pro- 
nunciation yet  more  faulty,  swallowing  nearly 
impossible. 

We  can  well  realize  what  risky  results  late  pros- 
thesis of  the  lower  jaw  gave,  up  to  the  time  that 
the  apparatus  of  CI.  Martin — when  he  created  his 
admirable  method  for  bloodless  correction  of  vicious 
scars — allowed  of  late  corrections  which  it  had  been 
impossible  to  achieve  before  his  time.  To  place  an 
apparatus  for  late  prosthesis  of  the  lower  jaw,  it  is 
necessary  to  reduce  the  cicatricial  band  in  two 
directions.  We  must  first  carry  the  remaining 
fragments  forwards  and  outwards  until  we  re-estab- 
lish the  interdental  articulation;  and  then  depress 
the  cicatrix  from  above  downwards,  to  hollow  out 
of  it   in   some  way  a  bed  receiving  the   prosthetic 


BLOODLESS  TREATMENT  OF  VICIOUS  SCARS     25 

apparatus  which  shall  re-establish  the  continuity  of 
the  mandibular  arch. 
Appliances  to  pull  on  the  Mandibular  Fragments. — 

The  aim  of  these  is  to  carry  the  remaining  segments 
of  the  jaws  into  a  position  of  abduction  until 
the  interdental  articulation  is  re-established.  The 
majority  of  these  appliances  take  their  purchase 
from  outside  the  mouth  by  the  interposition  of  a 


Fig.  12. — ^ Apparatus  to  pull  on  the  INIandibular  Fragments. 

(CI.  Martin.) 


casque  encircling  the  head.  CI.  Martin  has  success 
fully  employed  an  apparatus  composed  of  the  follow 
ing  pieces  (Fig.  12) : 

1.  A  metal  gutter  encircling  all  the  teeth  of  the 
remaining  segment  of  the  deviated  jaw.  In  the 
incisive  region  is  soldered  a  rod,  bent  into  a  semi- 
circle to  allow  free  movement  to  the  lower  lip.  This 
rod  bears  a  hook  at  its  end. 

2.  A  metal  band  surrounds  the  head  like  a  crown. 
On   this   crown   is   fixed,   on   the   side   opposite   the 


26  INJURIES  OF  THE  FACE  AND  JAW 

resected  part  of  the  jaw,  at  the  level  of  the  temporal 
fossa,  a  second  metal  rod  continued  downwards  for 
the  length  of  the  ascending  ramus,  and  descending 
to  the  level  of  the  mouth.     It  bears  a  ring  at  its  end. 

3.  A  strand  of  rubber,  stretched  between  the  ring 
of  the  temporal  rod  and  the  hook  of  the  buccal  rod, 
pulls  the  deviated  segment  outwards.* 

Frey,  with  a  similar  appliance,  has  published 
some  excellent  results. t 

Delair  has  made  an  apparatus  based  on  the  same 
principle,  a  spring  acting  on  the  dental  arch  and 
taking  its  point  d'apptii  from  a  casque.  This  ap- 
paratus consists  essentially  of  a  steel  rod,  of  which 
one  of  the  ends  is  fixed  to  a  metal  gutter  covering 
the  teeth  of  that  bone  segment  which  one  wishes  to 
reduce;  the  other  end,  rolled  up  on  itself  to  form  a 
closely  coiled  spiral  spring,  is  held  at  the  level  of 
the  occiput  by  a  casque  made  of  bands  of  aluminium, 
which  encircle  the  head  in  different  directions  (Figs. 
13  to  16). 

This  spring,  curved  inwards  in  a  half-circle  to  pass 
round  the  cheek,  has  then  its  fixed  point  at  the 
occiput,  and  its  movable  point  of  action  at  the  jaw 
which  calls  for  reduction.}:  Its  action  is  powerful; 
it  carries  the  jaw  segment  forwards  and  outwards, 
and  quickly,  in  a  few  days,  it  re-establishes  the  inter- 
dental articulation,  which  is  thereafter  maintained. 

*  Cl.  Martin,  "  Treatise  of  Immediate  Prosthesis." 
t  Frey,  "  Gunshot  Fracture  of  the  Whole  of  One  Ascending 
Ramus  of  the  Lower  Jaw:  Prosthetic  Treatment  "  (National 
Dental  Congress,  Cherbourg,  1905). 

+  Delair,   "  Exhibition  of  an  Apparatus  for  replacing  the 
Jaw  in  Position  "  [Odontologie,  28  Fevr.,  1906,  p.  157). 


BLOODLESS  TREATMENT  OF   VICIOUS  SCARS     27 

However,  apparatus  with  casques  are  open  to  severa 
criticisms : 


Fig.  15.  Fig.  16. 

Figs.  13  to  16. — Traction  Apparatus  of  Delair. 

I.  They  are  fatiguing  for  the  patient;  the  spring 
passing   between   the   lips   near   to  the  commissure 


28  INJURIES  OF  THE  FACE  AND  JAW 

provokes  a  flow  of  saliva  difficult  to  prevent ;  to  wear 
the  casque  becomes  quite  distressing  and  even  pain- 
ful; the  projection  of  the  spring  at  the  level  of  the 
cheek  and  the  occiput  is  very  irksome  when  lying 
down;  lastly,  the  appliance  attracts  attention  to  the 
patient  who  wears  it,  and  prevents  him  from  going 
out  and  attending  to  his  work. 

2.  The  apparatus  is  comparatively  quite  compli- 
cated to  make,  and  the  execution  is  not  so  simple  as 
the  idea. 

With  these  reservations,  one  must  admit  that 
Delair's  appliance  attains  the  end  aimed  at,  and 
rapidly  brings  into  abduction  the  cicatricial  bands 
which  follow  a  partial  resection  of  the  horizontal 
ramus  of  the  lower  jaw. 

Frey,  having  applied  in  one  case  the  more  simple 
elastic  traction  appliance  of  Martin,  has  obtained  a 
very  fine  success.  None  the  less,  in  his  notes  of  the 
case,  drawn  up  with  extreme  exactness,  we  observe 

the  following  remark:  "At  this  time  S fell  ill 

with  a  serious  pleuro-pneumonia,  and  all  prosthetic 
interference  was  stopped.  It  is  very  probable  that, 
despite  antiseptic  douches,  the  irritation  of  the 
mucosa  provoked  by  our  efforts  allowed  some  patho- 
genic organisms  to  infect  the  respiratory  passages. 

Moreover,   the  weather  was  warm,   and   S was 

tired  by  his  casque  and  by  the  loss  of  saliva;  for  the 
strand  of  stretched  elastic  which  attached  the  ap- 
paratus to  the  casque  kept  the  mouth  for  ever  open."* 

*   Frey,  "  Remarks  on  Prosthesis  of  the  Lower  Jaw.     Indi- 
cations for   Immediate   Prosthesis  "   {Revue    de  Stomatologie , 
Juin,  1903). 


BLOODLESS   TREATMENT  OF  VICIOUS  SCARS     29 

We  consider  this  quotation  to  be  the  best  illustra- 
tion of  the  general  criticisms  which  we  have  just 
been  levelling.  In  taking  stock  of  the  disadvantages 
of  appliances  which  take  their  point  d'appui  from  a 
casque,  one  of  us  has  been  persuaded  to  make  this 
point  d'appid  intrabuccal  by  the  use  of  the  following 
small  appliance.*  A  capsule  of  stamped  metal  covers 
the  premolars  and  first  and  second  molars  of  the 
upper  jaw  on  the  side  opposite  the  resection.  This 
capsule,  bearing  at  its  posterior  end  and  on  its  outer 
surface  a  hook  opening  backwards,  is  fixed  on  the 
teeth  with  cement  like  an  ordinary  metal  crown. 
A  similar  capsule  is  sealed  in  the  same  way  on  to 
the  deviated  fragment  of  the  lower  arch,  but  it  fits 
on  to  a  group  of  teeth  farther  forward,  maybe  the 
canine  and  premolars.  On  the  outer  surface  of  its 
anterior  end  is  soldered  a  hook  opening  forwards. 
An  elastic  band  with  a  buttonhole  at  each  end  en- 
gages these  hooks  (Fig.  17). 

The  fixed  point  d'appiii  is  formed  by  the  upper 
jaw,  and  under  the  action  of  the  traction  produced 
by  the  rubber  the  mandible,  displaced  inwards  and 
backwards,  steadily  corrects  itself,  and  in  a  few 
weeks  retakes  its  normal  position.  This  little  appli- 
ance, resembling  those  used  by  orthodontists,  causes 
no  fatigue  to  patients,  and  gives  rise  to  none  of  the 
objections  to  which  those  which  take  an  extrabuccal 
support  from  a  metal  casque  are  liable.     It  is  ex- 

*  Georges  Lemerle,  "  Appliance  of  Reduction  after  Resec- 
tion of  the  Lower  Jaw"  {Le  Lahoratoire,  2.Ci  Janv.,  1908,  and 
Societe  d'Odontologie,  Juin,  1906). — Sebileaii  and  Lemerle. 
Soc.  de  Chir.,  26  Dec,  1906. 


30  INJURIES  OF  THE  FACE  AND  JAW 

tremel}^  easy  to  make,  and  that  is  an  interesting 
consideration.  Whatever  be  the  appHance  used,  the 
abduction  of  the  fragments  of  a  resected  mandible 
is  generally  achieved  easily.  To  depress  the  scar 
tissue  from  above  downwards  is  beyond  all  comparison 
a  more  lengthy  and  difficult  matter  to  negotiate 
satisfactorily. 

Apparatus  for  pulling  down  the  Band  of  Scar 
Tissue. — The  object  of  these  is  that,  once  the  abduc- 
tion of  the  jaw  segments  is  accomplished,  they  shall 
gradually  depress  the  cicatrix,  ultimately  hollowing 


Fig.   17. — Reduction  Apparatus  of  G.  Lemerle. 

out  of  it,  as  it  were,  a  cell  to  contain  the  final  appli- 
ance of  late  prosthesis.  Martin  achieves  this  reduc- 
tion by  the  use  of  a  slow  and  continuous  pressure 
by  heavy  appliances  fitted  with  pieces  of  tin.  Since 
the  originator  of  this  plan  demonstrated  its  use, 
there  has  been  no  alteration  in  this  method;  and  this 
is  the  best  evidence  of  its  adequacy. 

Granted,  fox"  instance,  a  resection  extending  from 
the  angle  of  the  jaw  to  the  vertical  level  of  the  pre- 
molars of  the  same  side,  Martin's  appliance  is  built 
up  as  follows:  After  taking  the  impression  of  the 
remaining    teeth,    one    fashions    a    piece    of    rubber 


BLOODLESS  TREATMENT  OF   VICIOUS  SCARS     3] 

taking  its  support  from  the  latter.  This  piece  ol 
rubber  is  prolonged  backwards,  making  a  narrow 
border  as  far  as  the  position  of  the  original  angle 
of  the  jaw.  After  several  days,  when  the  patient 
is  thoroughly  accustomed  to  wearing  this  appliance, 
one  adds  a  piece  of  tin  extending  the  whole  length 
of  the  cicatrix,  and  fitting  on  the  lower  border  of  the 
rubber — i.e.,  the,  border  in  contact  with  the  mucosa. 
The  appliance  is  thus  also  lifted  upwards  (Figs.  18 
and  19). 

At  the  end  of  five  or  six  weeks,  thanks  to  the 
weight  of  the  tin  slab  and  the  pressure  exercised 
by  the  teeth  of  the  upper  jaw  during  mastication, 
the  upper  rim  of  the  appliance  becomes  lowered  to 
the  same  level  as  the  alveolar  border  of  the  opposite 
side.  Then  one  adds  another  piece  of  tin,  which 
causes  a  further  sinking,  later  a  third,  and  so  on 
until  the  scar  has  completely  yielded.  The  heavy 
apparatus,  driving  back  the  scar  tissue,  scoops  out 
at  the  site  of  the  original  gingivo-buccal  groove  a 
hollow  big  enough  to  lodge  a  final  appliance  replacing 
the  missing  part  of  the  jaw.  One  of  us  has  used 
since  1898  an  appliance  of  this  kind  which  has  given 
him  the  finest  results.  The  patient  had  undergone 
operation  for  a  sarcoma  of  the  mandible.  The  re- 
section extended  from  the  right  lower  canine  to  the 
condyle.  The  cicatricial  bands  were  thick,  under 
great  tension,  and  pulled  towards  them  the  remaining 
part  of  the  lower  jaw,  displacing  the  fragment  in- 
wards.    The  apparatus  was  composed  of — 

I.  A  platinum  cage,  which  covered  nearly  every 
part  of  the  fragment  of  the  mandible;  it  extended 


32  INJURIES  OF  THE  FACE  AND  JAW 

downwards  a  long  way,  thus  taking  a  firm  support 
from  the  jaw,  and  not  from  the  teeth,  so  that  the 


Fig.   i8. — Apparatus  built  up  with  all  its  Pieces.      (Martin.) 


Figs.  19  and  21. — Pieces  for  expanding  the  Heavy  Appliance 
of  ^lartin,  seen  separately. 

latter  were  protected.     To  this  cage  were  soldered 
two  strong  rods  of  German  silver;  the  object  of  these 


BLOODLESS  TREATMENT  OF   VICIOUS  SCARS     33 

was  to  bear  a  piece  of  brown  rubber,  with  a  shape 
and  curve  resembhng  the  mandible.  This  rubber 
itself  rested  on  the  cicatricial  bands.  The  upper 
part  of  the  rubber  came  in  contact  with  the  teeth 
of  the  corresponding  maxilla,  which  provided  the 
points  of  contact  requisite  to  re-establish  the  articu- 
lation; the  lower  or  basal  portion  and  the  inter- 
mediate part  in  the  cheek  were  intended  slowly 
to  distend  the  cicatricial  bands  by  progressive 
addition  to  the  bulk  of  the  appliance,  and  by  the 
mechanical  massage  exercised  by  the  apparatus  on 
the  tissues  during  the  various  movements  of  the  jaw 
(Fig.  20). 

2.  An  upper  appliance  in  platinum,  to  which  is 
soldered  vertically  on  the  right  side  another  small 
platinum  plate,  almost  rectangular  in  shape.  This 
small  plate  on  its  buccal  side  glided  on  another, 
rubber  plate,  which  in  turn  was  fixed  to  the  platinum 
cage  by  a  screw.  The  two  plates,  mutually  gliding 
on  each  other,  were  intended  to  prevent  lateral 
movements,  so  that,  during  the  motions  of  the  lower 
jaw  in  opening  the  mouth,  the  portion  of  bone  spared 
by  the  surgeon  should  be  always  kept  in  its  normal 
position. 

On  the  left  side  a  strong  spiral  spring,  attached 
by  means  of  spring-holders,  was  placed,  to  exercise 
a  vertical  pressure  strong  enough  to  stretch  little  by 
little  the  cicatricial  bands.  In  proportion  as  the 
bands  yielded  and  relaxed,  one  added  to  the  lower 
and  outer  aspects  of  the  appliance  a  thickness  of 
gutta-percha;  this  was  destined  to  be  replaced  by 
brown  rubber  at  the  time  when  the  next  apparatus, 


34 


INJURIES  OF  THE  FACE  AND  JAW 


which  was  naturally  more  bulky,  should  be  made. 
Fifteen  days  after  the  first  apparatus  had  been  placed 
in  position,  the  spring  was  removed  without  any 
trouble,  and  the  apparatus  was  well  in  place;  the 
steady  stretching  of  the  cicatricial  bands  took  place 
simply  by  adding  to  the  volume  of  the  apparatus. 
Several  appliances  of  this  sort  should  precede  the 
final  apparatus  furnish'^d  with  teeth.     In  this  final 


Fig.  20. — Appliance  for  Restoring  the  Lower  Jaw.  (Martinier. 

apparatus  one  replaces  the  brown  rubber  on  the  inner 
and  outer  surfaces  by  pink  rubber;  this  is  essential 
for  aesthetic  reasons. 

To  sum  up:  Confronted  with  a  patient  who  has 
undergone  a  partial  or  total  resection  of  one  or  other 
jaw,  the  goal  of  prosthetic  treatment  should  be — 

I.  To  re-establish  the  physiological  functions  of 
the  jaws. 

IL  To  give  to  the  face  its  normal  appearance. 


I3L00DLESS  TREATMENT  OF  VICIOUS    SCARS     35 

We  can  arrive  at  this  goal  by  a  survey  of  the  two 
phases  which  we  have  described: 

1.  Phase  of  correction  of  scar  tissue. 

2.  Phase  of  prosthesis  proper. 

The  first  of  these  phases  comprises  the  following 
procedures : 

{a)  Taking  a  plaster  impression. 

(6)  Constructing  the  skeletal  or  basal  part  of  the 
correcting  appliance,  of  which  the  objects  are — 

(i.)  To  assure  its  retention. 

(ii.)  To  resist  the  displacements  of  the  fragments, 
(iii.)  To  stretch  the  cicatricial  bands. 

3.  Trying  the  appliance  in  the  mouth.  Before 
doing  so  we  shall  have  attached  a  mass  of  wax  or 
composition,  with  the  object  of  moulding  the  parts 
on  which  the  appliance  will  rest  and  the  parts  with 
which  it  will  be  in  contact.  At  the  same  time  we 
shall  instantly  re-establish  articulation  with  the 
teeth  of  the  corresponding  upper  jaw. 

4.  Reproduction  in  rubber  of  the  piece  of  wax  or 
composition,  or  the  casting  in  tin  of  this  piece, 
according  to  the  case. 

5.  Placing  in  position  the  first,  provisional  ap- 
paratus, and  attentive  watching  of  the  tissues  on 
which  they  rest  or  against  which  they  press. 

6.  Any  modification  of  the  appliance. 

7.  Making  successive  provisional  apparatus,  and 
modifications  brought  to  bear  on  these,  if  such  be 
necessary. 

The  second  phase,  referred  to  above  as  prosthesis 
proper,  comprises: 

(a)  The  combined  construction  of  the  final  appara- 


36  INJURIES  OF  THE  FACE  AND  JAW 

tus  bearing  artificial  teeth,  and  the  various  parts  of 
the  apparatus,  which  should  conform  as  far  as  possible 
to  the  lines  of  the  face. 

[h)  Placing  the  apparatus  in  the  mouth  and  making 
the  requisite  final  touches.  To  get  a  good  result  one 
needs  time  and  patience.  Fifteen  days  to  a  month 
are  enough  to  obtain  abduction  of  the  deviated 
section  of  bone;  but  twelve  to  fifteen  months  are 
wanted  to  depress  the  cicatrix  vertically  and  make 
it  ready  to  accommodate  a  final  prosthesis.  That 
is  why,  whenever  possible,  one  should  make  use  of 
preoperative  appliances. 

Preoperative  Appliances. — When  the  application  of 
an  immediate  prosthesis  at  the  time  of  resection  of 
the  lower  jaw  is  not  indicated,  or  if  we  intend  to  fix 
there,  subsequently,  a  late  internal  prosthesis,  we 
must  seek  to  prevent  the  inward  and  backward  re- 
traction of  the  remaining  fragment  of  the  jaw.  In 
other  words,  we  strive  at  the  outset  to  conserve  for 
the  remaining  moiety  its  normal  position;  and  we 
do  not  delay  in  resisting  the  effects  of  cicatricial 
contraction  until  these  are  obvious. 

Be  it  understood  that  these  appliances  for  mini- 
mizing the  retraction  of  the  jaw  can  only  be  used 
where  we  are  concerned  with  a  resection  which  was 
partial,  and  where  some  of  the  jaw  persists. 

When  the  surgeon  has  defined  the  extent  of  his 
operation,  CI.  Martin  places  on  that  bony  segment 
which  is  fated  to  persist  an  appliance  of  vulcanized 
rubber  which  encloses  the  remaining  teeth;  to  the 
latter  it  is  fixed  by  screws,  if  it  cannot  grip  sufficiently 
by  itself. 


BLOODLESS  TREATMENT  OF  VICIOUS  SCARS     37 

This  appliance  bears  an  -external  lateral  wing 
pointing  upwards,  controlled  by  a  second  wing  which 
is  part  of  a  similar  appliance  attached  to  the  upper 


Fig.   22.— Preoperative  Prosthetic  Appliance  of  CI.  Martin: 

Upper  Piece. 

jaw.  The  upper  wing  is  on  the  inner  side  of  the  lower ; 
this  helps  the  latter  to  resist  the  pull  of  the  muscles 
on  the  remaining  piece  of  the  mandible  and  the 
retropulsion  resulting  from  scar  retraction.* 


Fig.  23. — Preoperative  Prosthetic  Appliance  of  CI.  Martin: 

Lower  Piece. 

'  When  the  wound  has  healed,  CI.  Martin  finishes 
the  work  by  pressing  down  the  scar  tissue  by  means 
of  his  heavy  appliances,  until  he  can  re-establish  the 

*  It  is  of  importance,   for  this  purpose,   that  the  surface 
of  gliding  of  the  wings  should  be  in  the  form  of  a  groove.    • 


38  INJURIES  OF  THE  FACE  AND  JAW 

continuity  of  the  jaw  by  means  of  a  final  prosthetic 
apparatus*  (Fig.  24). 

One  of  us  has  on  several  occasions  availed  himself, 
in  the  clinic  of  his  chief,  M.  Sebileau,  of  the  following 
device  by  way  of  a  preoperative  appliance:   some 


Fig.   24. — Final  Prosthetic  Apparatus  showing  the  Purpose 

of  the  Wings. 


metal  capsules  sealed  on  to  the  teeth  and  joined  by 
an  elastic  band,  as  described  in  a  previous  section. 
This  scheme  of  prophylaxis  against  early  deformi- 
ties following  on  resections  of  the  mandible  has 
always  given  the  best  results.     We  go  so  far  as  to 

*  CI.  Martin,  "  Preoperative  Prosthesis  " :  Congres  de  Lyon 
Aout,  igo6  {Laboratoire,  i8  Nov.,  1906). 


BLOODLESS  TREATMENT  OF  VICIOUS  SCARS     39 

say  that  no  resection  of  the  mandible  should  be 
undertaken  unless  it  is  either  followed  by  an  im- 
mediate prosthesis  or  preceded  by  a  preoperative 
appliance.  One  or  other  of  these  will  serve  the 
purpose  of  checking  the  immediate  displacements 
following  surgical  intervention,  and  will  afterwards 
allow  of  the  use  of  a  late  external  or  internal  pros- 
thesis. 

III.  Reduction  of  Nasal  Deformities. 

Deformities  of  the  nose  owe  their  origin  to  lesions 
of  the  skull  bones  consequent  on  either  trauma, 
syphilis,  or  tuberculosis.  The  bony  framework  is 
sometimes  merely  deformed,  sometimes  has  suffered 
a  loss  of  substance  more  or  less. 

The  straightening  of  the  nose  may  be  effected  by 
either  a  sudden  or  a  gradual  correction. 

I.  Sudden  Correction  is  especially  indicated  after 
fractures  affecting  the  nasal  skeleton.  At  an  early 
moment  the  fracture  is  reduced.  Thereafter  a  suit- 
able prosthetic  appliance  maintains  the  reduction. 
CI.  Martin  has  designed,  to  effect  this  reduction,  a 
surgical,  forceps  which  greatly  facilitates  its  per- 
formance.* 

Sudden  correction  has  been  used  with  equal 
success  in  some  cases  of  nasal  deformity  due  to 
vicious  union  of  certain  fractures  or  to  specific  lesions. 
In  such  cases  the  treatment  is  firstly  surgical,  then 
prosthetic. 

The  surgical  stage  comprises  the  breaking  down  of 

*  Congres  dent,  internat.,  Paris,  1900, 


40  INJURIES  OF  THE  FACE  AND  JAW 

cicatricial  bands  or  the  osteotomy  of  the  nasal  bones 
joined  in  a  faulty  position. 

The  prosthetic  stage  consists  in  the  application  of 
an  apparatus  to  hold  the  nose  in  a  correct  position. 
Sauer  and  Skogsborg  in  German}',  and  Aeyrapaa  in 
Russia,  have  obtained  by  this  method  satisfactory 
results,  following  Kingsley,  who  since  1868  made 
experiments  in  this  direction.  But  it  is  above  all 
CI.  Martin  who  extended  this  procedure  to  a  large 
number  of  cases  and  systematized  its  technique. 

Once  the  scar  tissue  has  been  freed,  the  difficulty 
lies  in  finding  a  solid  support  for  the  apparatus  which 
is  to  be  kept  there.  The  walls  and  borders  of  the 
nasal  fossse  only  supply  the  most  mediocre  supports. 
The  best  is  that  which  may  be  borrowed  from  an 
upper  denture  when  a  perforation  of  the  palate 
coexists.  When  no  such  perforation  exists,  one  can, 
as  exemplified  by  Aeyrapaa,  trephine  the  palatine 
vault  to  make  a  passage  for  a  metalhc  rod  to  sustain 
the  apparatus  which  is  to  hold  up  the  nose.  We 
consider,  with  CI.  Martin,  that  this  is  the  best  method 
for  retention  of  these  nasal  correction  appliances. 
The  palatine  perforation  is  not  specially  difficult  to 
make,  nor  does  it  entail  any  functional  disability  for 
the  patient. 

2.  Gradual  Correction. — This  is  applicable  to  the 
majority  of  cases  treated  by  the  preceding  method, 
but  is  particularly  called  for  when  the  deformity 
concerns  mainly  the  fleshy  or  cartilaginous  parts  of 
the  nose. 

To  raise  a  depressed  and  thickened  septum,  CI. 
Martin    has    thought    out    the    following    appliance: 


BLOODLESS  TREATMENT  OF  VICIOUS  SCARS     41 

Two  parallel  sheets  of  hardened  rubber  are  joined  at 
their  front  part  by  a  U-shaped  spring.  Their  free 
ends  are  buried  fore  and  aft  in  the  nasal  fossae  on 
each  side  of  the  septum.  At  the  front  end  of  these 
plates  are  articulated  two  similar  plates.  These 
latter  are  movable  in  a  vertical  plane,  and  are  lifted 
up  in  this  direction  by  a  spring  placed  near  to  their 
point  of  junction  with  the  lower  plates.  This  spring 
consists  of  an  annealed  gold  wire,  which  can  be  bent 
to  any  desired  shape.  As  CI.  Martin  puts  it,  the  upper 
plates  move  on  the  lower  like  the  blade  of  a  pocket- 
knife  in  its  handle. 

This  appliance  acts  by  taking  its  purchase  from 
the  two  sides  of  the  septum  and  the  floor  of  the  nasal 
fossae.  The  two  lower  plates,  compressing  the  septum 
in  the  transverse  plane,  tend  to  diminish  its  thick- 
ness and  lengthen  it  vertically.  The  upper  plates, 
gently  urged  by  the  springs,  lift  up  the  whole  front 
part  of  the  nose.  Thus,  the  combination  of  these 
two  movements  tends  to  give  to  the  nose  a  more 
prominent  and  a  narrower  shape.  To  get  satis- 
factory results,  this  apparatus  should  be  continuously 
worn,  and  should  not  be  removed  except  for  just 
enough  time  to  cleanse  it.  The  force  of  the  springs 
should  be  regulated  so  that  their  pressure  never 
becomes  painful.  This  type  of  appliance  can  be 
modified  according  to  the  variations  of  the  cases, 
and  CI.  Martin  has  made  several  depending  on  this 
principle.  He  says:  "  For  the  twenty-five  years  that 
I  have  used  them,  I  have  obtained  with  these  appli- 
ances some  excellent  results.  None  the  less  one  can 
make  two  adverse  criticisms:   First,   they  act   very 


42  INJURIES  OF  THE  FACE  AND  JAW 

slowly;  secondly,  the  anterior  spring  is  visible  ex- 
ternally below  the  columella.  This  latter  drawback 
is  negligible  in  children  and  young  people,  and  it  is 
precisely  in  this  category  that  I  use  this  mode  of 
correction  for  preference.  Therefore  I  do  not  hesitate 
to  recommend  it,  because  I  have  got  and  am  getting 
in  my  practice  some  fine  results."* 

3.  Corrective  Apparatus  for  the  Nose.— These  are 
intended  to  remedy  congenital  or  acquired  nasal 
deformities,  when  the  bony  and  cartilaginous  frame- 
work is  still  preserved. 

We  can  distinguish  two  sorts  of  apparatus : 

{a)  Apparatus  to  dilate  the  nostrils  and  reshape 
the  septum. 

(b)  Apparatus  to  reshape  flattened  noses. 

{a)  Dilators  of  the  Nostrils. — CI.  Martin  has  con- 
structed many  appliances  of  this  sort,  consisting 
essentially  of — 

Two  vulcanized  rubber  plates  which  are  placed  in 
the  nostrils  on  either  side  of  the  septum.  An  anterior 
spring  which  joins  these  two  plates  and  holds  them 
against  the  septum.  Two  other  plates  of  hard  rubber 
which  glide  on  the  first  plates,  imitating  the  move- 
ment of  a  knife-blade  in  its  handle.  By  means  of 
a  spring  these  two  plates  are  applied  to  the  upper 
part  of  the  nasal  fossae,  thus  dilating  the  nostrils  in 
the  vertical  direction,  simultaneously  raising  the 
lobule  and  the  soft  parts  (Fig.  26). 

To  efiect  a  transverse  widening  of  a  nostril,  CI. 
Martin  applied  an  appliance  consisting  of  two  sheets 
of  vulcanized  rubber  joined  along  one  side  by  the 

*   CI.  Martin,  "  Rapport  au  Congres  de  Madrid,"  1903,  p.  31. 


BLOODLESS  TREATMENT  OF   VICIOUS  SCARS     43 

same  substance.  One  of  these  sheets  rested  against 
the  septum,  the  other  against  the  inner  surface  of  the 
ala  to  be  dilated.  The  appHance  for  straightening 
the  septum  comprises  two  upright  plates  of  vulcanized 
rubber  corresponding  in  size  to  the  deviation,  which 
are  applied  to  each  side  of  the  septum  by  means  of 
a  spring  placed  in  front. 


Fig.  25. — Continuous  Pressure  Apparatus.     (Martin.) 

In  these  appliances  the  parts  which  have  to  exercise 
pressure  on  the  mucosa  are  covered  with  rubber  to 
guard  against  ulceration. 

{b)  Apparatus  to  reshape  Flattened  Noses. — An 
attempt  has  been  made  to  reshape  saddle-back  noses 
by  means  of  rods  of  rolled  metal,  which  fitted  by  one 
end  on  to  the  floor  of  the  nasal  fossae,  and  by  the  other 
propped  up  the  nasal  bones.     No  results  were  ob- 


44  INJURIES  OF  THE  FACE  AND  JAW 

tained;  the  rolled  metal  rod  slipped  down  in  the 
nasal  fossa  and  ceased  to  act. 

*  CI.  Martin  has  invented  an  apparatus  which  is 
certain  of  achieving  its  purpose,  is  not  cumbersome, 
allows  of  nasal  breathing,  and  is  hardly  visible.  It 
consists  of — 

(i.)  Two  plates  of  vulcanized  rubber  to  lie  on  the 
nasal  floor  and  thus  give  a  stable  support  to  the 
spring. 

(ii.)  A  gold  ware  which  follows  the  contours  of  the 
lower  outline  of  the  nostrils  and  unites  the  two  plates. 


Fig.    26. — Nasal  Dilator.      (Martin.) 

to  which  it  is  attached  by  a  hinge.  The  hinge  gives 
a  large  range  of  movement  to  the  plates,  and  allows 
them  to  lie  snug  against  the  nasal  floor.  This  gold 
wire  is  barely  visible,  and  may  be  made  still  less 
noticeable  if  covered  with  pink  rubber. 

(iii.)  Two  springs  of  gold  wire,  varying  in  shape 
according  to  the  point  on  which  they  are  to  act; 
these  emerge  from  the  upper  surface  of  the  intra- 
nasal plates,  and  end  in — 

(iv.)  Two    tongues    of    hardened    rubber,    applied 


BLOODLESS  TREATMENT  OF   VICIOUS  SCARS     45 

against  the  nasal  vault,  which  they  lift  up  and 
replace  in  its  normal  shape. 

The  introduction  of  this  apparatus  is  easy,  and 
causes  no  annoyance  when  in  place  (Fig.  27). 

CI.  Martin,  for  narrowing  the  root  of  a  nose  which 
is  as  wide  above  as  below,  uses  an  appliance  which 
takes  its  support  from  the  front  part  of  the  septum 
and  the  floor  of  the  nasal  fossae;  by  means  of  two 
springs  and  two  small  plates  the  arrangement  pinches 
the  upper  and  external  part  of  the  nose. 


Fir..   27.— Appliance  for  Flattened  Noses.      (Martin.) 

The  correction  takes  a  long  time;  surgeon  and 
patient  must  equip  themselves  with  an  enormous 
deal  of  patience.  As  a  reward,  we  can  promise  the 
patient  that  if  he  wears  the  apparatus  consistently 
success  is  certain. 

4.  Cicatricial  Stenosis  of  thie  Oro-Pharynx.* — CI. 
Martin  has  had  occasion  to  apply  his  system  of 
bloodless  correction  of  cicatricial  bands  at  the  site 
of  a  cicatricial  narrowing  of  the  oro-pharynx.     For 

*  Cl.  Martin,  Congres  de  Madrid. 


46  INJURIES  OF  THE  FACE  AND  JAW 

this  particular  case  he  devised  the  following  appara- 
tus, consisting  of  two  parts: 

(i.)  A  palatine  plate  fixed  in  the  usual  way  to  the 
teeth,  and  completely  covering  the  palate. 


Fig.  28. — Adhesions^of   Palate Jand  Pharyngeal   Wall  :   Cast 
of  the  Mouth  and  Pharynx  before  Operation.      (Delair.) 

(ii.)  A  dilating  apparatus  constituted  by  a  spring 
screwed  on  to  the  middle  of  the  plate.  This  spring  is 
made  of  an  annealed  gold  wire  feebly  stretched,  and 
shaped  like  a  compass  of  which  the  limbs,  bent  back 
in  a  curve,  diverge.     Their  lower  ends  are  prolonged 


BLOODLESS  TREATMENT  OF  VICIOUS   SCARS      47 

into  two  semi-hard  rubber  balls.  When  the  ap- 
paratus is  in  place,  these  balls  press  against  the 
boundaries  of  the  narrowed  part,  and  the  two  branches 
of  the  spring  cause  the  widening  of  the  stenosis. 


Fig.  29. — Palatc-Pharyngeal  Adhesions:  Cast  o^  the  iMouth 
and  Nose  after  Operation.     (Delair.l^ 


5.  Palato-Pharyngeal  Adhesions. — The  same  prin- 
ciples find  a  happy  application  for  the  correction 
of  adhesions  between  palate  and  pharyngeal  wall. 
Having  freed  the  adhesion  of  the  velum  to  the 
pharyngeal  wall,  one  has  to  prevent  any  new  ad- 


48 


■INJURIES  OF  THE  FACE  AND  JAW 


hesions  from  forming  until  the  bleeding  surfaces  have 
completely  healed,  meanwhile  keeping  these  apart. 
CI.  Martin  has  obtained  the  best  results  with  the 
following  apparatus:  A  block  of  rubber  in  the  shape 
of  the  pharynx  is  made  by  means  of  a  mould  taken 
from  the  cadaver.  This  block  is  kept  in  place  by 
two  prolongations  entering  the  posterior  nares,  and 
ending  in  two  rubber  tubes  which  emerge  from  the 


>     11 

•^; 

Fig.  30. — Palato-Pharyngeal  Adhesions:  Delair's  Appliance, 
seen  from  Below,  with  the  Carriage  and  the  Dilators. 

nostrils.  These  facilitate  easy  retention  of  the  whole 
arrangement.  The  wearing  of  this  apparatus,  for 
the  whole  period  of  cicatrization,  enables  one  to 
prevent  the  formation  of  new  adhesions. 

Delair*  (Figs.  28  to  32)  also  has  made  an  apparatus 

*   Delair,    "^Demonstration   of  a   Child  wearing  a  Dilator 

of   the  Naso-Pharynx  :    Delair's  Plan  to  counteract  Palato- 

haryngeal  Adhesions  "  {Odontologie,  15  Juillet,  1909,  p.  12). 


BLOODLESS  TREATMENT  OF  VICIOVS  SCAHS     49 

to  correct  adhesions  of  the  palate.  It  depends  on 
a  mechanism  which  is  ingenious,  but  more  comphcated 
than  the  pharyngeal  separator  of  CI.  Martin  above 
described.  Delair's  apparatus  comprises  four  pieces, 
as  follows: 

I.  A  metallic  palatine  plate  kept  in  place  by  rings 
fitted  to  the  teeth. 


Fig.  31. — Delair's  Appliance,  seen  from  Above,  with  the 
Projection  caused  by  the  Upper  Longitudinal  Groove, 
in  which  glides  the  Safety- Screw. 

2.  In  the  centre  of  this  plate  a  carriage;  this  is  of 
gold,  and  consists  of  two  pieces  joined  along  their 
contiguous  surfaces  in  an  antero-posterior  direction. 

3.  At  the  end  of  the  carriage,  two  movable  branches 
like  the  limbs  of  a  compass,  embracing  the  concavity 
of  the  velum  and  encircling  the  uvula  to  prevent  any 
trauma  of  this  latter. 

4.  The   two   movable   branches   are   furnished   at 

4 


50 


INJURIES  OF  THE  FACE  AND  JAW 


their  ends  with  two  prolongations  of  aluminium, 
destined  to  lie  on  the  postero-superior  aspect  of  the 
velum  after  it  has  been  surgically  freed. 

The  several  sections  of  this  apparatus  play  one 
upon  the  other,  and  coax  the  velum  free  in  various 
directions,    with    the    help    of    elastic    traction.     A 


YiG.  2)Z. — Diagram  to  show  the  Details  of  Delair's  Apparatus 

in  Place. 


rubber  ring  connects  the  carriage  of  the  palatine 
plate,  producing  a  pull  from  above  and  behind;  this, 
acting  on  the  velum,  prevents  it  from  again  touching 
the  posterior  pharyngeal  wall.  Some  other  rubber 
strands  pull  on  the  movable  articulated  branches  of 
the  carriage,  making  them  diverge.     This  movement, 


LATE  PROSTHESIS  51 

occurring  in  a  transverse  plane,  moves  outwards  the 
extreme  borders  of  the  newly  formed  velum,  and 
prevents  the  raw  edges  from  coming  into  mutual 
contact  in  the  middle  line. 

Delair's  appliance  has  undoubtedly  the  advantage 
that,  much  lighter  than  Martin's  and  of  very  small 
bulk,  it  is  much  less  irksome  to  him  who  wears  it. 
Nevertheless,  Martin's  has  one  great  merit,  its  simple 
construction;  and  for  an  apparatus  essentially  tem- 
porary, and  which  has  to  be  worn  only  for  a  few 
weeks,  this  is  an  advantage  not  to  be  despised.* 


CHAPTER  III 
LATE  PROSTHESIS 

The  Prosthetic  Stage  Proper. 

By  "  late  prosthesis  "  is  meant  the  prosthetic  restora- 
tion of  losses  of  substance  due  to  accident  or  surgical 
interference,  such  restoration  being  performed  at  a 
smaller  or  greater  interval  after  the  complete  healing 
of  the  soft  parts.  In  the  preceding  chapter  we  saw 
that  the  retraction  of  scar  tissue  brings  in  its  train 
divers  deformities,  and  we  have  studied  the  methods 
used  to  rectify  this.  In  the  matter  of  late  prosthesis, 
it  is  the  stage  of  cicatricial  contraction  which  beyond 
doubt  offers  the  greatest  difficulty.  Late  prosthesis 
proper — that  is,  the  final  appliance  to  remedy  the 
loss  of  substance  after  obtaining  correction  of  scar 

*  Mixed  velo-palatine  prosthesis:  surgical  and  prosthetic 
method.  Vide  Prosthetic  Intervention  after  Staphylor- 
rhaphy, Chapter  III. 


52  INJURIES  OF  THE  FACE  AND  JAW 

tissue — constitutes  a  very  much  easier  phase  of  the 
restoration.  We  shall  study  in  sequence  late  ap- 
paratus for  restoration  of  the  jaws,  the  soft  and  hard 
palates,  the  larynx,  the  bucco-facial  region,  the  nose, 
and  so  on. 

I.  Late  Prosthesis  of  the  Jaws. 

Apparatus  and  methods  vary  according  to  whether 
we  are  concerned  with  the  upper  or  lower  jaw.  But 
we  will  now  point  out  certain  rules  which  must  be 
kept. 

Impressions.— We  take  impressions  in  plaster  for 
choice;  plaster  exerts  but  a  moderate  pressure  on 
the  tissues,  and  thus  the  replica  which  it  provides  is 
a  faithful  copy  of  the  supporting  tissues,  cicatricial 
or  otherwise,  when  these  are  at  rest.  W^e  are  often 
obliged  to  make  a  special  impression  tray  for  the  case 
in  hand.  W'ith  this  idea  we  take,  using  an  ordinary 
impression  tray,  a  rough  cast  of  the  tissues  which 
the  appliance  is  ultimately  to  support.  We  cast  this 
impression,  and  on  the  model  thus  obtained  we 
make  the  impression  tray  either  by  stamping  it  on 
a  sheet  of  German  silver,  or  by  making  a  tray  in 
wax  and  substituting  for  it  vulcanized  rubber  or 
aluminium  cast  in  the  wax.  By  means  of  this  tray 
it  becomes  easy  to  bring  the  substance  used  for  the 
impression  in  contact  with  all  the  tissues,  exercising 
an  equal"jif)ressure  at  all  points. 

It  is  often  necessary,  in  anfractuous  cavities,  to 
take  the  impression  in  several  parts;  this  composite 
impression  (see  p.  183)  gives,  when  it  is  assembled, 
the  total  impression. 


LATE  PROSTHESIS  .53 

Apparatus. — The  apparatus  is  furnished  with  teeth 
on  the  alveolar  border.  We  employ  for  choice 
vulcanized  rubber  for  making  them.  The  base  is 
made  of  undressed  brown  rubber,  which  is  at  the 
same  time  lighter  and  firmer;  the  gums  in  pink 
rubber ;  and  the  backing  or  lingual  cusp,  if  necessary, 
of  white  rubber.  The  base  may  equally  well  be  made 
of  cast  aluminium,  which  is  so  well  tolerated  by 
mucous  membranes.  We  more  often  use,  for  the 
bases  in  bulky  appliances,  soft  rubber,  which  has  the 
following  advantages: 

1.  It  causes  no  pain  by  pressure  on  the  tissues 
which  are  in  contact  with  it. 

2.  Its  elasticity  facilitates  the  removal  of  the 
appliances,  and  therefore  their  cleaning. 

3.  It  does  not  lessen  the  humidity  of  neighbouring 
tissues.  Hence  its  usefulness  for  prosthetic  appli- 
ances in  contact  with  the  nasal  mucosa.  Apparatus 
used  after  resections  of  the  mandible  may  con- 
veniently be  massive;  for  by  their  weight  they  resist 
the  cicatricial  deformities  of  neighbouring  tissues 
and  facilitate  the  lowering  of  the  jaw. 

For  lower  jaw  appliances  destined  to  replace  large 
losses  of  substance,  it  is  good  to  introduce  into  the 
rubber  to  be  vulcanized,  at  the  moment  of  packing, 
some  fragments  of  rubber  themselves  previously 
vulcanized,  or  some  pieces  of  tin,  to  get  rid  of  the 
porosity  caused  by  the  unusual  thickness  of  the  part 
to  be  produced. 

It  is  by  no  means  the  same  thing  with  the  upper 
jaw  appliances  designed  to  remedy  the  functional 
troubles  following  a  loss  of  substance  after  a  surgical 


54  INJURIES  OF  THE  FACE  AND  JAW 

Operation,  or  resulting  from  congenital  default.  In 
such  case  lightness  is  a  condition  indispensable  to 
success.  These  appliances  are  often  bulky;  to  pre- 
serve the  necessary  size,  all  the  while  maintaining 
the  lightness  which  is  imperative,  the  thickest  parts 
must  be  hollow.  It  has  been  suggested  to  incorporate 
in  them  a  block  of  aluminium ;  but  this  metal,  howbeit 
light,  is  still  too  heavy,  and  the  results  have  not 
been  satisfactory.  Another  experiment  has  been  the 
introduction  of  pieces  of  cork  in  the  rubber,  at  the 
time  of  the  packing  of  the  apparatus.  The. best  plan 
is  to  leave  a  cavity  in  the  centre  of  the  thick  parts 
of  the  contrivance. 

To  get  this  result  we  avail  ourselves  of  various 
processes : 

The  appliance  is  flasked  as  usual.  We  cover  with 
a  sheet  of  rubber  the  deep  part  of  the  apparatus. 
In  the  hollow  thus  formed  we  pour  a  certain  amount 
of  plaster,  representing  what  is  to  be  the  cavity. 
The  plaster  once  hardened,  and  the  seams  loosened, 
we  carry  on  the  packing,  as  if  we  had  to  make  a 
piece  of  an  ordinary  prosthesis.  The  block  of  plaster 
is  thus  included  in  the  centre  of  the  rubber. 

Geoff roy*  has  published  an  interesting  process  for 
obtaining  extremely  light  apparatus.  We  cannot 
here  describe  the  technical  details.  Enough  to  say 
that  the  hollow  is  obtained  by  means  of  two  light 
boxes  in  stamped  aluminium,  and  covered  outside 
by  rubber.  They  are  exactly  adapted  by  their 
borders,  and  united  by  the  rubber  which  serves  as 
their  common  envelope. 

*  Geoffrov,  "  Hollow  Appliances  for  Restorative  Pros- 
thesis "  {Odontologie,  30  Aout,  1906,  p.  166). 


LATE  PROSTHESIS 


55 


As  a  rule,  prosthetic  appliances  come  into  contact 
with  cicatricial  tissue  which  is  more  fragile  than 
normal  tissues;  so  the  appliance  should  not  possess 
sharp  angles,  its  rough  points  should  be  carefully 
rounded  off.  Moreover,  as  we  have  already  pointed 
out,  we  prevent  contusions  and  undue  pressure  on 
the  tissues   by  using   soft   rubber   for  those   points 


Fig.  2>2>- — Late   Prosthesis  for  the  Upper   Jaw,   as  used  bv 
Pont  of  Lyons. 


which  have  to  be  against  them.  Pont*  has  ex- 
hibited an  entirely  original  apparatus  for  the  restora- 
tion of  the  upper  jaw  (Figs.  33  and  34). 

*  Pont,  "  General  Considerations  on  Restorative  Prosthesis 
for  the  Upper  Jaw.  Exhibition  of  a  New  Apphance  " 
[Odontologie,  v.,  1903,  p.  471).  We  must  also  call  attention 
to  an  important  memoir  recounting  seventeen  cases  of  pros- 
thetic restoration  after  resection  of  the  upper  jaw.  Vide 
Billing,  "Von  der  Obsrkiefer  Resektions  Prothese,"  Stock- 
holm, 1 91 2;  Isaac  Marcus,  editor. 


56 


INJURIES  OF  THE  FACE  AND  JAW 


This  apparatus  consists  of  a  hard  vulcanized 
rubber  palatine  plate,  supporting  artificial  teeth 
and  resembling  an  ordinary  denture.  This  plate  is 
surmounted  by  a  soft  rubber  pocket  closely  approach- 
ing to  the  shape  of  the  maxilla  or  of  the  missing  part. 
A  gold  tube,  sunk  into  the  palatine  plate,  puts  this 
pocket   into   communication  with  the  outer  world. 


Fig.  34. — Late  Prosthesis  for  the  Upper  Jaw :  Pont  of  Lyons 


The  inner  end  of  the  tube  is  closed  by  a  valve,  and 
the  outer  end  by  a  pivot  which  supports  one  of  the 
false  teeth  of  the  apparatus. 

When  the  patient  wants  to  wear  this  arrangement, 
he  has  only  to  empty  the  pocket  of  air.  It  is  easy 
to  flatten  the  pocket  and  put  the  appliance  in  place. 
This  done,  the  patient  with  a  pear-shaped  inflator 
refills  the  pocket  with  air,  and  it  swells  and  hardens. 


LATE  PROSTHESIS  57 

In  this  way  its  retention  is  complete.  The  advantage 
of  this  apphance  is  its  extreme  lightness.  Moreover, 
it  can  be  used  with  effect  for  treating  vicious  scars. 


II.  Prosthesis  for  Soft  and  Hard  Palate. 

Perforations  or  losses  of  substance  of  the  velum 
or  hard  palate  may  be  congenital  or  acquired.     In 
the  latter  case  they  occur  most  often  from  tertiary 
syphilis.     The  functional  disabilities  vary  in  degree 
with  the  amount  of  substance  lost ;  nasal  speech  may 
be  noticed,  and  the  escape  of  liquid,  or  occasionally 
solid  food,  from  the  nose.     The  patient  experiences 
great   difficulty  in  swallowing,   above   all  of   fluids; 
he  throws  back  his  head  and  drinks  in  tiny  mouth- 
fuls.     Nearly   always   phonation    is    heavily    handi- 
capped, even  to  the  point  of  being  quite  unintelligible. 
We  cure  these  incapacities  by  methods  surgical  or 
prosthetic;  the  indications  for  these  respective  plans 
are  drawn,  as  we  shall  see  later,  now  from  the  age 
of  the  patient,  now  from  the  extent  of  the  lesion. 
But  the  functional  gain  accruing  is  very  variable, 
according   to    whether   we    are    concerned   with   an 
acquired  perforation  or  a  congenital  fissure.     In  the 
former  the  cure  of  speech  is  rapid,  sometimes  even 
immediate.     Varying  with  the  sort  of  case,  a  simple 
obturator  plate  or  a  flexible  velum  generally  suffices 
to     correct     functional    troubles    perfectly.     "  This 
fact,"  says  A.  Martin,   "  is  easily  explained  by  the 
existence   of   previously   educated   muscles;    and   in 
these  cases  the  imperfect  speech  depends  rather  on 
mechanical  defects  resulting  from  the  lesion  than  on 


58 


INJURIES  OF  THE  FACE  AND  JAW 


the  abnormal  play  of  the  muscles.  Thus,  it  suffices 
to  re-establish  these  mechanical  conditions  in  sup- 
pressing the  communication  between  the  mouth  and 
the  post -nasal  space,  for  speech  to  redevelop  as  pure 
as  of  yore. 

"  The  treatment  of  congenital  losses  of  substance 


Fig.    t,^. — Cast  of  a  Hare-Lip.      (Deiair.) 

is  different,  and  presents  complex  difficulties.  To 
create  anew  the  normal  mechanical  conditions  never 
suffices  to  obtain  a  rapid  and  satisfactory  functional 
result.  The  fact  is  that  in  these  cases  the  chief 
impediment  arises,  not  only  from  the  actual  loss  of 


LATE  PROSTHESIS  59 

substance,  but  above  all  from  the  atrophy  of  muscles, 
and  because  their  education  has  been  nil  or  faulty. 
So  far  is  this  a  truism  that,  even  with  a  good  appara- 
tus, we  get  an  insignificant  result  as  regards  speech. 

"  The  prosthetic  treatment  should  then  always  be 
followed  by  a  period  of  re-education  of  speech, 
necessary  to  obtain  a  good  final  result,  but  which 
itself  would  not  be  enough."* 

Now,  as  we  shall  see  later,  this  is  a  consideration 
often  not  fully  realized.  In  the  matter  of  congenital 
fissures  of  the  velum,  one  cannot  repeat  too  often 
that  a  long  speech-training  is  indispensable.  Ortho- 
phonia  must  be  deemed  the  logical  outcome  of  all 
efforts  for  restoration,  surgical  or  prosthetic,  and  the 
majority  of  functional  failures  may  be  lain  at  the  door 
of  negligence  of  this  paramount  rule. 

There  are  two  methods  to  cure  clefts  of  the  soft 
or  hard  palate:  (i)  surgical,  (2)  prosthetic. 

I.  Surgical  or  Autoplastic  Method. — We  can  only 
deal  with  this  in  passing.  By  two  parallel  incisions 
at  the  palatine  cleft  we  can  elevate  the  mucosa,  and 
by  sliding  bring  together  the  two  flaps  thus  obtained. 
We  thereafter  freshen  their  edges,  and  suture  them 
in  the  mid-line.  When  our  object  is  to  reconstruct 
the  hard  palate  we  use  the  term  "uranoplasty"; 
when  the  soft  palate  is  concerned  it  is  a  "  staphylor- 
rhaphy." The  immediate  post -operative  outcome 
is  sometimes  very  pretty.  But  the  functional  results 
are  not  constant,  because  too  often  the  surgeon 
neglects  the  observation  and  after-care  of  the  velo- 
palatine  scar  tissue.  We  have  seen  in  an  earlier 
*  CI.  Martin,  Cong.  Madrid,  p.  45. 


6o  INJURIES  OF  THE  FACE  AND  JAW 

chapter  that  the  character  of  scar  tissue  depends  on 
its  retractihty;  but  it  is  this  very  elasticity  which 
enables  it  to  elongate  and  soften  easily  by  pressure 
or  traction,  gentle  and  continuous,  or  at  any  rate 
frequent.  Later  we  shall  see  how  systematic  massage 
of  the  velum,  after  staphylorrhaphy,  makes  it  supple 
and  able  to  resist  shortening.  In  certain  cases,  even 
to  wear  an  appliance  resembling  an  elastic  ball  for 
a  brief  space  gives  a  fair  amount  of  lengthening. 

2.  Prosthetic  Method. — This  comprises  essentially 
two  sorts  of  apparatus:  artificial  vela  and  obturators. 
The  object  of  artificial  vela  is  an  anatomical  restoration. 
The  paramount  end  to  he  gained  by  obturators  is  a 
functional  restoration,  and,  neglecting  the  reconstitution 
of  the  loss  of  substance,  their  only  destiny  is  to  correct 
its  results  by  occluding  the  abnormal  communication 
existing  between  the  month  and  the  naso-pharynx. 

Certain  authors  (CI.  Martin,  Delair,  NormaiJ 
Kingsley)  have  sought  to  combine  in  one  apparatus 
these  different  principles.  Petronius  in  1565  spoke 
of  palatine  obturators,  and  recommended  wax,  tow, 
sponge.  Ambroise  Pare  described  two  sorts  of 
obturators  for  fissures  of  the  hard  palate,  consisting  of 
a  metal  plate  and  a  sponge.  Fauchard  combined 
obturators  with  dentures,  and  omitted  the  sponges 
hitherto  employed.  Bourdet  noticed  the  tendency 
of  acquired  palatal  fissures  to  close  spontaneously, 
and  invented  a  series  of  obturators  consisting  of  a 
simple  plate  of  gold,  held  by  wires,  and  intended  to 
encourage  the  reunion  of  the  edges  of  the  perforation. 
Delabarre  in  1820  introduced  into  their  construction 
a  soft  hinged  velum.     In  1823  Snell  discovered  one 


LATE  PROSTHESIS  6i 

of  the  most  important  principles  of  this  special 
prosthesis:  to  communicate  to  the  artificial  velum 
the  movement  of  the  remaining  stumps  of  the  palate. 
In  1840  Stearn  made  an  obturator  on  this  plan,  and 
Schange  in  1841  made  the  first  model  entirely  in 
gold.  Kingsley  in  1864  constructed  an  artificial 
velum  by  means  of  two  superposed  sheets  of  soft 
rubber;  the  stumps  of  the  velum  fitted  in  between 
these,  and  communicated  to  them  their  mobility. 
Gariel  in  1855  made  an  obturator  in  vulcanite  having 
the  form  of  a  double  shirt  button.  Preterre  has  made 
a  large  number  of  obturating  arrangements  and 
artificial  vela,  deriving  his  ideas  from  those  of  Stearn, 
carried  out  with  greater  simplicity.'''' 

After  Preterre,  the  study  of  velo-palatine  prosthesis 
came  to  a  halt  in  France,  although  in  Germany 
Suerson,  then  Brugger,  gave  it  a  great  impetus.  In 
these  latter  years,  CI.  Martin  and  Delair  in  France, 
and  Calvin  Case  in  the  United  States,  have  published 
important  work  on  the  question;  and  velo-palatine 
prosthesis  seems  now  to  be  in  good  working  order, 
at  any  rate  as  far  as  concerns  its  underlying  principles. 

Prosthesis  for  the  Hard  Palate. — The  disabilities 
resulting  from  losses  of  substance  of  the  palatine 
vault  are  easily  curable.  It  is  sufficient,  in  order  to 
cure  the  functional  trouble,  to  fit  an  obturator  con- 
sisting of  a  palatine  plate  which  takes  its  point  d'appui 
from  the  neighbouring  teeth,  and  adapts  itself  exactly 
to  the  circumference  of  the  perforation.  This  plaque 
may  be  of  either  metal  or  vulcanite.     It  must  pass 

*  Preterre,  "  Treatise  of  Congenital  or  Acquired  Fissures 
of  the  Soft  and  Hard  Palate,"  Paris,  1884. 


62  INJURIES  OF  THE  FACE  AND  JAW 

across  the  perforation  like  a  bridge,  without  penetrating, 
because  small  losses  of  substance,  notably  of  the  ac- 
quired variety,  tend  to  fill  up  spontaneously.  The 
appliance  must  not  hinder  this  tendency  to  repair. 

Contrivances  which  pass  through  the  perforation  and 
take  their  support  from  the  floor  of  the  nasal  fossce  are 
thus  absolutely  contra-indicated. 

Prosthesis  for  the  Soft  Palate. — When  the  lesion 
involves  the  velum,  the  difficulty  is  much  greater 
than  in  the  preceding  case.  To  replace  by  a  pros- 
thetic appliance  a  muscular  and  eminently  mobile 
organ  presents  almost  insurmountable  difficulties. 
Hence  the  legion  of  contrivances  suggested  and  the 
faulty  results  often  achieved.  The  importance  of 
an  artificial  velum  varies  according  to  the  size  of  the 
fissure.  The  greater  the  breach,  the  more  is  it  worth 
while  to  fill  it  up. 

Impression. — The  material  of  choice  is  plaster; 
a  special  impression  tray  is  useful.  But  it  is  often 
preferable  to  fashion  it  in  the  way  already  mentioned 
in  the  earlier  book.*  For  it  is  rarely  that  impression 
trays  when  made  have  the  desired  measurements; 
this  is  especially  true  as  regards  the  height  of  the 
palatine  vault.  We  must  make  many  trials  until 
we  succeed  in  getting  the  velum  and  the  stumps  of 
its  pillars  in  a  state  of  relaxation.  In  this  case  even 
more  than  in  any  other  it  is  expedient,  from  the 
moment  that  the  plaster  is  introduced  into  the  mouth, 
to  lower  the  patient's  head,  so  that  no  plaster  runs 
into  his  throat.     In  the  event  of  requiring  an  im- 

*  Vide  p.  Martinier  and  G.  Villain,  "  Clinique  de 
Prothese." 


LATE  PROSTHESIS  63 

pression  of  the  edges  of  the  perforation  and  the  naso- 
pharynx, we  take  one  impression  (see  p.  183)  super- 
posed on  the  other ;  or  we  can  adopt  the  plan  described 
apropos  of  the  apparatus  of  Calvin  Case. 

Contrivance  of  the  Apparatus. — The  apparatus  is 
divided  into  two  parts:  one  fixed,  the  other  movable. 
The  first  or  fixed  part  forms  the  base  plate.  It  is 
rigid,  extends  along  the  surface  of  the  palatine  vault, 
and  takes  its  point  of  attachment  from  the  teeth  by 
means  of  the  various  arrangements  in  practice  for 
retention  of  apparatus.  If  we  have  a  combined 
lesion  of  the  soft  and  hard  palates,  it  answers  also 
as  an  obturator.  This  part  may  be  in  vulcanite  or 
metal.  It  should  be  fitted  as  accurately  as  possible, 
so  that  the  obturator  may  be  very  rigid. 

The  second  or  movable  part  is  as  a  rule  in  soft 
rubber,  less  often  in  hard  rubber  or  metal.  It  plays 
the  part  of  velum,  and  should  have  as  far  as  possible 
the  same  relations  and  physiological  movements  as 
does  the  velum  under  normal  conditions.  It  should 
fit  on  to  the  borders  of  the  cleft,  and  follow  smoothly 
whatever  movements  the  stumps  of  the  natural  velum 
can  impart  to  it. 

These  two  parts  are  united  at  the  junction  of  the 
hard  and  soft  palates  by  an  articulation  which  dift'ers 
with  the  importance  of  the  gap  and  the  type  of 
appliance  used:  sometimes  there  is  no  line  of  demarc- 
ation, but  simply  soft  rubber  succeeding  hard;  some- 
times there  is  a  small  hinge.  This  articulation  must 
be  very  mobile  and  very  delicate,  so  as  to  react  to 
the  least  movement ;  it  must  not  become  dirty,  which 
would  check  the  working  of  the  appliance.     Having 


64 


INJURIES  OF  THE  FACE  AND  JAW 


framed  these  general  laws,  we  will  study  a  few  of  the 
best-known  apparatus. 

Simple  Appliance  without  a  Hinge. — This  apparatus 
consists  of — • 

I.  A  palatine  plate  extending  no  farther  than  the 
level  of  the  palate  bones;  it  is  sometimes  of  metal, 
usually  of  hard  vulcanite,  and  is  prolonged  backwards 
in  the  direction  of  the  velum  in  the  form  of  a 
stanchion. 


Fig.  36. — Simple  Appliance  without  a  Hinge.      (^lartinier.) 

'2.  A  plate  of  soft  rubber  corresponding  to  the  loss  of 
soft  tissue  in  the  hard  and  soft  palates,  and  lying 
over  the  edges  of  this  gap.  The  palatine  and  velo- 
palatine  plates  are  continuous  without  the  inter- 
position of  a  hinge  or  other  joint.  The  hard  part, 
which  is  continued  into  the  centre  of  the  soft  rubber, 
acts  as  its  guide,  and  keeps  it  along  the  borders  of 
the  perforation  (Fig.  36). 


LATE    PROSTHESIS  6$ 

The  artificial  velum  so  made  has  been  adversely 
criticized  in  that  it  does  not  possess  the  desired 
mobility.  When  hrst  inserted  and  the  palate  is  in 
repose,  it  shuts  off  the  cleft  well;  but  in  the  move- 
ments of  swallowing  it  lits  badly  and  hampers  the 
physiological  work  of  neighbouring  muscular  struc- 
tures. After  the  lapse  of  some  time  the  soft  rubber 
becomes  misshapen  under  the  influence  of  this  con- 
tinuous pressure,  and  ceases  to  tit  even  in  repose. 
It  hardens,  and  its  mobility,  never  reliable,  becomes 
still  less.  It  cracks  and  becomes  severed  from  the 
palatine  plate  at  its  point  of  union  with  the  latter. 


Fig.   37. — Kingsley's  Appliance. 

But  above  all  we  must  indict  this  artificial  velum  of 
a   faulty   functional  restoration;    this,    moreover,    it 
shares  more  or  less  with  all  appliances  which  shut 
off  the  naso -pharynx  only  incompletely. 
Kingsley's  Appliance. — This  consists  of — 

1.  A  palatine  plate  of  vulcanite  or  metal. 

2.  An  artificial  velum  of  soft  rubber. 

3.  A  hinge  to  join  these  two  parts  and  assure  free 
movement  to  the  artificial  velum  (Fig.  37). 

This  hinge  does  not  put  beyond  doubt  the  close 
fitting  of  the  remaining  muscular  parts.  To  it  we 
must  also  add  a  spring  which  keeps  it  snug  against 


66  INJURIES  OF  THE  FACE  AND  JAW 

the  borders  of  the  hole.  This  spring  may  be  inferior 
- — i.e.,  buccal;  in  this  case  it  consists  of  a  sheet  of 
flattened  gold  fixed  to  the  base  plate,  playing  on  the 
velo-palatine  part  which  it  carries  upwards  in  the 
movements  of  swallowing.  Or,  again,  the  spring 
may  be  superior — i.e.,  nasal — in  which  case  it  con- 
sists of  a  spiral  spring,  fixed  in  front  to  the  base 
plate,  and  behind  to  the  artificial  velum,  which  it 
lifts  upwards.  Thus,  it  is  certain  that  the  latter 
maintains  contact  with  what  remains  of  the  soft 
palate.  A  rubber  ring  can  be  substituted  for  the 
spiral  spring,  fixed  in  the  same  way. 

Appliance    of  Guerini    of  Naples,'^ — This    consists 
of— 

1.  A  palatine  plate,  preferably  metallic. 

2.  An  artificial  velum  in  soft  rubber. 

3.  A  joint  uniting  these  two  parts. 

It  is  the  latter  (the  joint)  which  gives  originality 
to  the  arrangement.  It  comprises  a  series  of  small 
transverse  plates  joined  by  hinges,  constituting  in  this 
way  many  small  joints  which  give  the  obturator  a 
great  mobility  on  the  palatine  plate  [a  lobster-tailed 
joint — Tr.].  The  pressure  required  to  fit  the  appli- 
ance to  the  neighbouring  parts  during  all  their  move- 
ments is  provided  by  a  small  sheet  of  gold  perpendi- 
cular to  the  segments  of  the  lobster-tail,  forming  a 
spring.  This  small  sheet  is  yielding  enough  to  give 
way  to  movements  of  lowering,  meanwhile  carrying 
the  velum  upwards  in  movements  of  elevation 
(Fig.  38). 

*   "  New  System  of  Obturator  for  the  Soft  Palate  "  (Con- 
gres  dentaire  international  de  Paris) . 


LATE  PROSTHESIS  67 

Martins  Appliances — i.  Appliance  with  Bags  of 
Water. — Martin  did  not  rest  content  with  shutting 
off  the  buccal  from  the  naso -pharyngeal  cavities;  in 
order  to  obtain  a  practically  normal  voice,  he  entirely 


Fig.  s^. — ^Appliance  of  Giierini. 


replaced  the  lost  substance.  "  The  appliances  which 
we  use  are  of  hard  and  soft  rubber,  which  allows  us 
to  obtain  an  artificial  velum  having  the  free  play  of 
natural  vela.  Moreover — and  herein  lies  the  origin- 
ality of  our  system — we  replace  by  hollow  rubber 
bodies  all  the  lost  tissue,  so  as  to  give  to  the  buccal 


68 


INJURIES  OF  THE  FACE  AND  JAW 


and  nasal  cavities  their  natural  form.  This  is,  in 
fact,  the  only  plan  which  enables  us  to  obtain  a 
correct  pronunciation."* 

Consistent  with  this  principle,  Martin  constructed 
some  apparatus  bearing  at  their  posterior  end  globular 
masses  of  hollow  soft  rubber.  If  the  vomer  is  partly 
missing,  he  replaces  it  in  his  obturator  by  a  median 


Fig.    39.  - — Martin's  Appliance  with  Bags  of  Water. 

A,  Upper  bag  of  water;  B,  artificial  velum;  C,  nasal 
prolongation. 

projection  w^hich  meets  the  remains  of  the  natural 
vomer  (Fig.  39). 

So  as  to  give  more  mobility  to  the  obturator,  in 
order  that  it  may  be  able  to  follow  all  the  movements 
conveyed  to  it  by  the  muscles,  he  partly  fills  with 
fluid  the  shallow  cavity  in  the  hollow  soft  rubber 
situated  at  the  posterior  part.  He  gives  to  this 
obturating  part  the  shape  of  two  bags  joined  by  a 
constriction.  The  lower  bag  in  front  is  continuous 
with  the  palatine  plate  of  the  apparatus,  and  its 
upper  surface  lies  against  the  lower  surface  of  the 

*  Ci.  ]^Iartin,  "  Concerning  Immediate  Prosthesis,"  Paris, 
1889;  Masson,  editor. 


LATE  PROSTHESIS  69 

remaining  parts  of  the  velum.  The  upper  and  smaller 
±)ag  is  placed  in  the  nasal  fossae,  on  the  floor  of  which 
it  rests  by  its  inferior  surface,  overlapping  a  little 
the  borders  of  the  loss  of  tissue.  The  constricted 
part  joining  the  two  bags  corresponds  to  the  margin 
of  the  perforation,  which  are  thus  enclosed  by  the 
two  valves  {i.e.,  bags). 

The  two  bags  are  hollow,  and  communicate  by  an 
opening  at  the  level  of  the  constriction.  This  sub- 
divided cavity  is  partly  filled  with  fluid.  Under  the 
influence  of  the  muscular  movements  which  com- 
press the  lower  bag  its  contained  fluid  is  driven  into 
the  upper,  which  swells  and  presses  the  appliance 
snugly  on  the  nasal  floor.  The  apparatus  in  this 
way  follows  all  the  movements  of  the  velum,  and 
answers  to  every  muscular  impulse  conveyed  to  it 
by  the  surrounding  muscles.  By  altering  the  shape 
of  the  bags,  we  can  divert  the  fluid  into  convenient 
channels,  and  thus  obtain  movements  closely  re- 
sembling those  of  the  normal  velum. 

2.  Trap-Door  Obturators.  —  Meanwhile  Martin, 
changing  his  point  of  view,  has  invented  another 
obturator  called  a  "  trap-door,"  which  is  described 
in  his  own  words  as  follows:  "  It  consists  primarily 
of  a  palatine  piece  in  hard  rubber,  and  a  soft  or 
hard  velum  joined  together  by  a  hinge  (Figs.  40 
and  41). 

"  Above  the  velum  the  second  part  of  the  apparatus 
is  fixed ;  this  is  destined  to  fill  up  in  part  the  pharyngeal 
cavity.  It  consists  of  three  traps:  one  median  and 
two  lateral.  The  latter  present,  along  their  external 
borders,   a  gutter  where  the  stumps  of  the  velum 


-o  INJURIES  OF  THE  FACE  AND  JAW 

will  lodge ;  and  the  velum  will  communicate  to  these 
lateral  traps  their  movement.  In  transverse  section 
these  traps  are  triangular,  with  the  apex  inwards; 
and  the  lower  surface  of  one  rests  and  glides  on  the 
upper  surface  of  the  other.  The  median  valve  also 
is  triangular,  in  transverse  section,  the  apex  of  the 
triangle  pointing  downwards,  and  fits  into  the  angle 
fornned  by  the  two  lateral  traps;  its  lateral  aspects 
rest  and  move  on  their  upper  aspects.     When  the 


Figs.  40  and  41. — ^Martin's  Trap-Door  Obturator. 

Fig.   40. — Position  of  the  Traps  when  the  Pharyngeal  Muscles 

are  at  Rest. 
Fig.   41. — The  Same  during  the  Contraction  of  the  Pharyngeal 

Muscles. 


stumps  of  the  soft  palate  contract,  they  compress 
the  lateral  traps,  which  glide  one  on  the  other  by 
their  inclined  surfaces,  pressing  backwards  and 
upwards  the  median  trap,  which  becomes  pushed 
against  the  posterior  pharyngeal  wall.  During  re- 
laxation the  median  trap  descends  by  its  own  weight, 
opening  out  the  lateral  traps;  these  latter  return  to 
their   position  of  rest,  and  the  communication   be 


LATE  PROSTHESIS  71 

tween  the  pharynx  and  nasal  cavity  is  once  more 
patent."* 

To  make  these  hollow  appliances,  we  construct  a 
plaster  model  of  the  parts  which  are  to  be  represented 
by  hollow  rubber — that  is,  the  traps.  We  next 
cover  all'aspects  of  the  rubber  with  a  suflhcient  thick- 
ness of  plaster,  and  vulcanize  it.  We  take  out  the 
plaster  by  making  a  hole,  which  is  forthwith  tilled 
up  again. 


Fi(i.   42. — Valve- Velum. 

Delairs  Artificial  Valve-Velum.'f — This  contrivance 
is  founded  on  the  following  postulates  which  Delair's 
exhaustive  work  has  allowed  him  to  formulate: 

1.  The  basal  or  palatine  part  of  an  artificial  velum 
should  be  of  metal,  to  obtain  a  resonance  superior 
to  that  given  by  vulcanized  rubber. 

2.  The  velum,  whatever  its  shape,  should  be  soft 
and  supple. 

*  CI.  Martin,  Cong,  de  Madrid,  1903,  p.  54. 

t  Delair,  "  Artificial  Valve- Velum  "  (Cong.  dent.  nat. 
Ajaccio,  OdontjL,  Juillet,  1902,  p.  59). — "  On  Velo-Palatine 
Prosthesis"  {OdontoL,  1905,  p.  143). — "  New  MethoJ  of  Re- 
storative Velo-Palatine  Prosthesis  "  {OdontoL,  1901,  p.  ^j;}). 


72  INJURIES  OF  THE  FACE  AND  JAW 

3.  The  velum  should  be  united  to  the  palatine 
plate  by  an  absolutely  mobile  joint,  so  that  the 
former  may  be  able  to  follow,  in  their  movements  of 
elevation  and  depression,  the  stumps  of  the  cleft 
velum  and  the  faucial  pillars. 

4.  The  false  velum  should  extend  to  beyond  the 
limits  of  the  anterior  pillars,  so  as  to  close  the  pharyn- 
geal cavity,  and  thus  reduce  the  resonance.  The 
posterior  margin  of  this  velum  should  come  into 
accurate  contact  with  the  cushion  which  is  formed 
by  the  superior  pharyngeal  constrictor  during 
swallowing  and  phonation. 

Delair's  valve-velum  is  of  soft  rubber,  with  convex 
borders.  It  is  attached  to  a  fixed  denture  by  a 
hinge.  This  velum  passes  up  behind  the  posterior 
pillars,  and  ends  in  the  form  of  an  oval  cupola,  of 
which  the  flexible  and  thin  borders  tightly  fit  the 
contours  of  the  pharynx.  A  sort  of  valve  is  thus 
produced,  which  checks  the  passage  of  air.  When 
the  soft  rubber  perishes,  the  valve  can  be  changed. 
"To  facilitate  the  elevation  of  the  artificial  velum, 
and  allow  it  to  follow  the  excursions  of  the  natural 
one,  a  simple  soft  rubber  washer  serves  as  a  spring. 
It  is  held  b}^  a  rod  and  ring  at  the  top  of  the  posterior 
part  of  the  basal  plate,  and  is  caught  on  to  a  hook 
soldered  to  one  of  the  two  nuts  which  screw  the 
velum  to  the  movable  posterior  section  of  the  appli- 
ance." 

To  fashion  his  appliance,  Delair  simply  took  a 
mould  of  the  upper  jaw,  not  extending  be^^ond  the 
limits  of  the  bony  palate.  After  this  mould  he  made 
the  basal  retention  plate  or  denture.     To  construct 


I 


LATE  PROSTHESIS  73 

the  mobile  part — that  is,  the  artificial  velum  and  its 
valve  destined  to  shut  off  the  pharynx — the  author 
preferred  to  rely  on  measurements.  As  a  fact,  the 
margins  of  the  palatine  gap  and  pillars  have  a 
divergence  which  varies  consecutive  to  the  state  of 
rest  or  contraction  of  the  residual  stumps  of  soft 
palate.  Now,  the  taking  of  the  impression  (which 
necessitates  the  use  of  cocaine)  gives  the  position  of 
the  respective  remnants  of  velum  when  in  repose; 
and  if  a  valve  were  constructed  on  these  data  it 
would  be  too  small,  in  that  the  stumps  in  contracting 
increase  the  gape  of  the  fissure  margins.  As  a 
corollary  to  this,  the  final  apparatus  will  shut  off 
the  pharynx  only  when  in  a  state  of  rest ;  this  occlu- 
sion will  become  imperfect  at  the  exact  moment 
when  the  stumps  contract.  Delair  accordingly  took 
his  measurements  while  allowing  for  the  extreme 
gaping  of  the  edges  of  the  fissure,  which  he  obtained 
by  eliciting  muscular  contraction  by  tickling  the 
mucosa. 

A  certain   number  of  special   compasses   thought, 
out  by  the  author  are  requisite  (Figs.  43  to  45),  and 
enable  us  to  obtain  the  following  three  measurements : 

I.  Maximum  width  between  the  borders  of  the 
fissure. 

1^.  Maximum  distance  from  the  edges  of  the  uvula 
to  the  posterior  pharyngeal  wall. 

3.  Distance  between  the  lateral  pharyngeal  walls. 

Nevertheless,  we  ought  not  to  make  an  appliance 
having  these  exact  dimensions.  In  fact,  if  the  notch 
of  the  velum  at  the  level  of  the  pillars  measures 
exactly  the  same  as  the  maximum  distance  between 


74 


INJURIES  OF  THE  FACE  AND  JAW 


the  stumps,  there  is  a  risk  that  the  apphance  will 
ulcerate  the  mucosa  by  friction.  The  velum,  then, 
should  be  at  this  level  about  3  mm.  less  than  the 
hgure  obtained  by  measuring.     Likewise  the  valve 


YB 


Figs.  43  to  45. 


-Delair's  Compasses  for  Bucco-Pharyngeal 
^Measurements. 


should  be,  in  the  sagittal  plane,  about  2  mm.  less 
than  the  figure  obtained  by  measurement;  for  if  the 
valve  be  as  deep  as  the  pharynx,  the  occlusion  will 
be  complete  just  as  much  in  repose  as  during  con- 
traction, and  passage  of  air  for  respiration  will  become 


LATE  PROSTHESIS  75 

impossible.  Lastly,  if  the  breadth  of  the  valve 
correspond  to  the  transverse  space  between  the 
lateral  pharyngeal  walls,  the  friction  will  prevent  it 
from  rising  during  contraction;  hence  the  necessity 
of  making  it  narrower  by  3  mm. 

"  To  recapitulate,"  says  Delair,"^  "  in  the  case  of 
a  complete  cleft,  a  plate  denture,  bridging  the  palatine 
fissure  from  one  border  to  the  other,  will  form  a 
rigid  obturator  as  far  as  the  leyel  of  the  aponeurotic 
part  of  the  velum.  It  is  exactly  at  this  point,  which 
corresponds  to  the  anterior  surface  of  the  wisdom- 
teeth,  that  the  mechanism  of  an  artificial  valve- 
velum  should  be  fixed  on  to  the  denture.  Then, 
given  the  width  of  any  complete  fissure  whatsoever, 
we  shall  determine  that  of  the  artificial  velum  which 
we  have  in  hand  by  adding  7  to  8  mm.  to  each  margin, 
so  as  to  insure  absolute  contact  with  the  stumps 
during  their  maximum  separation^that  is,  in  swal- 
lowing, speaking,  and  singing.  Its  length  will  be 
less  by  i  cm.  We  have  studied  mathematically  the 
dimensions  to  be  given  to  the  two  notches  situated 
between  velum  and  valve.  Let  us  revert  to  this 
most  important  point,  for  on  the  perfect  grasp  of 
this  depends  success  in  many  cases. 

"It  is  understood  that  the  width  of  each  notch 
should  correspond  to  the  thickness  of  the  stump  of 
the  uvula,  which  it  should  cover.  This  thickness 
varies  in  different  cases;  its  average  is  from  4  to  6  mm. 
Each  notch  should  bestride,  as  it  were,  the  cor- 
responding stump  exactly  at   the  point   where   the 

*  Delair,  "  On  Velo-Palatine  Prosthesis  "  {Odontologie, 
15  Fevr..  1905.  P-  151)- 


76  INJURIES  OF  THE  FACE  AND  JAW 

remnants  of  uvula  and  velum  are  continuous.  As 
for  the  valve,  let  me  recall  in  passing  that  its  object 
is  to  shut  off  the  naso -pharynx  during  swallowing  as 
well  as  when  speaking  four-fifths  of  all  spoken  sounds. 
I  have  already  given  the  reason  wh}'  it  should  be 
joined  on  to  the  artificial  velum  proper;  I  demon- 
strated its  physiological  role  when,  two  years  ago, 


Fig.  46. — Horizontal  Section  of  a  Cleft  Palate. 


I  exhibited  several  patients  to  whom  it  had  been 
applied. 

"  As  regards  its  applicability,  I  repeat  that,  save 
only  in  the  rare  event  of  an  extremely  narrow  fissure, 
it  can  always  be  used. 

"  There  is  no  precise  anatomical  ratio  between  the 
width  and  the  depth  of  the  space  between  the  pharynx 
and  the  uvula  stumps.  As  a  fact,  the  tonsils  are 
often  a  cause  of  stenosis  of  the  cavity;  b}'  their  size 


LATE  PROSTHESIS  77 

they  sometimes  push  forward  the  anterior  pillars, 
which  enlarges  the  dimensions  of  the  space  to  be 
filled.  In  other  cases  they  are  rudimentary,  and  this 
space  is  narrower. 

"  The  valve  will  always  be  oval,  but  not  with  a 
geometrical  regularity.  Its  transverse  diameter  in 
front  should  be  straight  from  one  notch  to  the  other; 
and  its  posterior  border  should  have  a  slightly 
accentuated  curve,  so  as  to  fit  itself,  inside  the  naso- 
phar^^nx,  against  the  superior  pharyngeal  constrictor 
during  its  contraction."  ' 

Delair  has  instituted  a  table  showing  the  dimen- 
sions to  give  to  the  velum  and  valve  after  measuring 
the  pharynx.  He  classified  seven  principal  types 
corresponding  to  cases  met  with  in  practice.  We 
think  it  right  to  publish  this  table,  whose  value  in 
constituting  a  valve-velum  is  very  great.  As  we 
see,  according  to  this  table  of  proportions,  a  valve- 
velum  may  easily  be  applied  to  fissures  of  from 
20  to  30  mm.  and  more.  Below  these  measurements 
Delair  considers  that  staphylorrhaphy  is  indicated 
rather  than  prosthetic  apparatus.  The  valve -velum 
should  not  be  applied  at  once,  for  it  will  provoke 
reflex  contraction  of  the  pharynx. 

It  is  necessary  to  obtain  previously  a  tolerance 
of  the  pharyngeal  region  when  in  contact  with  the 
foreign  body  which  one  wishef  to  place  there.  With 
this  idea  we  first  of  all  make  the  patient  wear  a 
basal  plate,  which  meanwhile  acts  as  an  obturator 
in  any  case  of  cleft  palate. 

When  the  patient  is  accustomed  to  use  this  piece 
we  add  a  rubber  tongue  which  acts  as  a  sort  of  half 


78 


INJURIES  OF  THE  FACE  AND  JAW 


velum.     Some  days  later  this  demi- velum  is  replaced 
by  an  entire  velum. 

Later  we  substitute  a  valve-velum.  Latest  of  all 
and  finally,  when  tolerance  is  perfect,  we  fit  the 
complete  and  final  apparatus.  This  education  of 
the  pharynx  takes  about  three  weeks  (Delair). 


Measurements  taken  from 

Corresponding 

Nature. 

Measurements  of 

Vela. 

r  ^'         ~:z 

■^ 

S^' 

1^ 

^ 

^ 

<^ 

<4i  «s  ->~. 

•^  "?s     •        S 

^  „ 

•.^ 

.^ 

"^ 

^ 

<tt 

5^  «  s 

■■0 

^       ri 

5S 

"5 

■^ 
& 

Distance  b 
Stumps  of 

when  at 

Maximum 
between  Stum 
Contract 

Depth  of  Ph 
Cavit 

Distance  b 
Lateral  W 

Phary 

< 

""Si 

•'1 

mm. 

mm.    1  m.m. 

mm. 

mm. 

mm. 

mm. 

mm. 

I. 

23 

31      1     16 

^  47 

29 

48 

14 

44 

II. 

22 

30-5       16 

45 

275 

46 

14 

42 

III. 

21 

29          15 

43 

26 

44 

13 

40 

IV. 

20 

28          14 

42 

25 

42 

12 

38 

V. 

19 

26-51     13 

41 

^3-5 

41 

II 

38 

VI. 

i8 

25     :     14 

37 

22 

30 

12 

34 

VII. 

17 

23          12 

Z5 

20 

39 

10 

32 

Artificial  Velum  of  Calvin  Case* — This  appliance 
comprises  a  triangular  metal  plate  of  w^hich  the  apex 
points  forwards  and  the  base  backwards.  The 
margins  of  this  plate  are  fitted  with  a  soft  rubber 
tube   destined   to   make   contact   with   the   mucosa. 

*  Cahdn  Case,  "•  ^lechanical  Treatment  of  Congenitcil 
Fissures  of  the  Palatine  Vault  "  (Cong.  dent,  internaj:., 
Saint-Louis,  Aout,  1904;  Odontologie,  -^o  Oct.,  1905). 


LATE  PROSTHESIS  79 

The  rubber  tube  in  its  front  part  is  hollowed  out  to 
form  a  gutter  which  shall  receive  the  edges  of  the 
palatine  cleft  (Figs.  47  to  60).  In  front  the  appliance 
is  retained  by  a  metal  plate,  held  by  hooks  which 
clasp  the  neighbouring  teeth.  But  when  the  patient 
has  worn  the  obturator  in  this  way  for  some  time, 
and  is  quite  accustomed  to  it,  he  can,  according  to 
Calvin  Case,  dispense  with  the  palatine  plate  and 
hooks,  and  easily  keep  it  in  position. 

To  make  a  velum  on  Case's  model,  it  is  necessary 
to  take  the  exact  impression  of  the  buccal  and  nasal 
surfaces  of  the  fissure.  To  get  good  impressions  the 
author  advises  the  following  methods : 

"  (i)  Make  a  base  of  moulded  composition  on 
which  plaster  is  spread.     (2)  Use  plaster  only. 

"  For  the  first  of  the  above  methods,  we  smother 
the  index-finger  with  composition  and  press  it  gently 
into  position.  By  removing,  softening,  and  if  neces- 
sary reshaping  this  composition,  and  removing  the 
excess  several  times,  we  finally  obtain  with  this 
modelling  composition  an  impression  which  does  not 
dislocate  the  soft  posterior  margins,  and  which 
supports  perfectly  the  plaster  for  the  final  impression. 

"  The  palatine  surface  is  then  arranged  in  such  a 
way  that  the  plaster  adheres  to  it,  and  any  com- 
position which  spreads  above  the  nearest  borders  of 
the  fissures  is  cut,  and  the  trimmed  surface  is  joined 
and  oiled. 

"  When  the  mass  has  settled  down  in  position  with 
the  plaster,  we  need  not  apprehend  difficulty  in 
removmg  it,  even  though  the  plaster  be  in  excess, 
provided  that   it   does  not   encroach  forwards  over 


8o  INJURIES  OF  THE  FACE  AND  JAW 

the  alveolar  border  in  extensive  double  fissures.  For 
the  whole  of  that  part  which  extends  above  the  edge 
of  the  fissures,  and  takes  the  impression  of  the  nasal 
fossae,  will  come  away  easily  from  the  smooth  and 
oiled  surface  of  the  composition  when  the  impression 
is  removed.     In'ffact,   there  is  nothing  else  to  hold 


Figs.  47  and  48. — Different  Views  of  the  Plaster  Impression 
of  an  Extensive  Fissure.      (Calvin  Case.) 

it  to  the  lower  parts,  when  the  composition  forms  a 
complete  bridge  between  the  fissures  and  their  most 
neighbouring  borders. 

"  The  nasal  section  can  then  be  pressed  back 
towards  the  most  open  part  of  the  fissures,  and  we 
can  let  it  fall  on  tc^  a  dental  mirror,  and  then  replace 


LATE  PROSTHESIS 


8i 


it  on  the  impression.  Ordinarily  I  prefer  simple 
plaster,  assembled  in  parts  as  above,  at  the  margins 
of  the  cleft."* 


Figs.  49  and  50. — -Impression  in  Plaster  and  Composition. 

(Calvin  Case.) 

First  of  all  we  make  the  part  which  is  hollowed 
out  gutterwise,  and  should  enclose  the  borders  of  the 

*  Calvin  Case,  "  Mechanical  Treatment  of  Congenital 
Fissures  of  the  Palatine  Vault  "  (Cong.  dent,  internat., 
Saint-Louis,  Aout,  t  }o^;  Odontologie,  30  Oct.,  1905). 

6 


82  INJURIES  OF  THE  FACE  AND  JAW 


Fig.  31. — Different  Stages  in   taking  the  Impression. 
(Calvin  Case.) 


Fig.  52. — Buccal  Aspect  of         Fig.  53. — Nasal  View, 
the  Finished  Model.    (Cal-  (Calvin  Case.) 

vin  Case.) 


Figs.  54  and  55.— Arrangement  of  the  Metal  Wire  which  is 
to  serve  as  Support  for  the  Composition  for  an  Impres- 
sion of  the  Contracted  Pharynx. 


Fig.  56. — Lingual  Aspect 
and  Transverse  Section 
of  Case's  Appliance. 


Fig.  57. — Longitudinal  Sections 


Fig.     58. — Relations    of    the 
Appliance  to  the  Pharynx. 


Fig.  59. — Relations  of  the  Fig.  60. — Palatine  Plate 

Appliance  to  the  Stumps  of   Support. 

of  the  Velum.  (Calvin  Case.) 


84  INJURIES  OF  THE  FACE  AND  JAW 

palatal  fissure.  At  the  posterior  part  of  this  piece 
we  fit  two  metallic  tubes  into  which  fit  the  limbs  of 
a  copper  wire  staple.  This  staple  is  lengthened  or 
shortened  until  it  makes  contact  with  the  pharyngeal 
walls.  "  Having  adjusted  the  wire  to  mark  the 
desired  lines  of  the  velum,  a  roll  of  composition  can 
be  attached  to  the  staple,  following  the  contours  of 
the  peripheral  surface.  It  is  placed  warm  in  the 
mouth,  and  we  direct  the  patient  to  swallow;  after 
a  few  swallows  this  gives  a  perfect  impression  of  the 
outer  margin  of  the  zone  which  we  want,  when  the 
muscles  are  contracted  "  (Case). 

Artificial  Velum  of  Norman  W.  Kingsley.'^ — This 
appliance  consists  of  two  valves,  made  of  soft  rubber, 
joined  in  the  mid-line.  The  lower  valve  is  a  velum; 
it  covers  the  buccal  margin  of  the  fissure.  Its  usual 
shape  is  triangular.  The  most  acute  of  its  angles 
closes  the  apex  of  the  fissure,  and  its  base  is  placed 
across  the  uvula.  The  valve  is  superposed  on  the 
soft  parts,  which  restrain  it  in  so  far  that  it  cannot 
be  thrown  up,  across  the  fissure,  into  the  higher 
(naso-pharyngeal)  space.  The  upper  vahe  is  meant 
to  close  oh  the  pharyngeal  cavity.  Like  the  former 
one,  it  is  triangular,  but  its  base  extends  farther  back 
so  as  to  touch  the  pharyngeal  wall  (Fig.  6i). 

This  upper  valve  rests  with  its  nasal  surface  on 
the  palatal  fissure.  It  is  not  attached  to  the  lower 
valve,  save  along  the  middle  line.  I'hus,  between 
the  two  there  exists  a  gutter  in  whicli  the  margins  of 

*  B.  Ottolengui,  "On  Palatine  Fissures  ':  "American 
Textbook  of  Prosthetic  Dentistry,"  Philadelphia.  1907 
(Laboratoire,  4  Aout,  1907). 


LATE  PROSTHESIS  .  85 

the  fissure  fit,  as  in  the  velum  of  Calvin  Case.  The 
anterior  extremity  of  this  double  valve  is  fixed,  by 
means  of  a  metal  button,  to  a  palatine  plate;  this, 
again,  is  kept  in  place  by  hooks  which  encircle  the 
teeth.  The  manufacture  of  this  whole  contrivance 
requires  very  accurate  impressions  of  both  aspects 
of  the  margins  of  the  fissure.     They  can  be  taken 


Fig.   61. — Norman  Kingsley's  Velum. 


by  the  method  recommended  by  Calvin  Case  (Figs. 
51  to  53). 

Suersen's  Obturator. — In  1877  Suersen*  made  an 
entirely  original  contrivance,  which  at  that  time 
amounted  to  a  veritable  revolution  in  the  matter  of. 
velo-palatine  prosthesis  (Fig.  64). 

The  point  of  this  is  that  he  was  less  bent  upon  re- 
constituting the  velum,  but  strove  only  to  restore  function 
by  insuring  the  occlusion  of  the  naso-pharynx. 

To  attain  this  occlusion,  he  availed  himself  of  the 
pad   which   the    superior   constrictor   forms   on    the 

*  Sueisen,  "  On  Detects  of  the  Palate."  A  work  extracted 
from  the  "  Treatise  on  Operative  Dentistry,"  by  Robert 
Baume,  Leipzig,  1877,  edition  of  Arthur  Felix. 


86 


INJURIES  OF  THE  FACE  AND  JAW 


posterior  pharyngeal  wall.  The  appliance  used  for 
this  purpose  was  a  single  rigid  piece.  The  front  part 
covered  the  palatine  vault;  the  back  part  filled  the 


Figs.   62  and  63. — Norman  Kingsley's  Velum. 

whole  width  of  the  post-nasal  space.  The  superior 
constrictor  applied  itself  to  the  posterior  edge  of  the 
pharyngeal  part,  thus  attaining  the  occlusion  of  the 


LATE  PROSTHESIS  87 

naso -pharynx.  When  the  muscle  is  at  rest,  there 
remains  enough  of  a  sht  to  assure  the  passage  of  air 
for  breathing.  The  stumps  of  the  velum  no  longer 
have  to  play  any  part;  the  constrictor  by  itself  takes 
charge,  and,  at  the  moment  of  pronouncing  any  letters 
of  the  alphabet,  compels  the  column  of  air  to  pass 
via  the  mouth. 

Suersen's  appliance  is  made  of  hard  rubber.  First 
one  must  make  the  palatine  piece,  then  with  some 
gutta-percha  take  the  impression  of  the  pharynx. 
For  that,  one  arranges  behind  the  palatine  piece  a 


Fig.  64. — Suersen's  Obturator. 

lump  of  gutta-percha,  softened,  hlling  the  greater 
part  of  the  post-nasal  space.  Taking  advantage  of 
the  short  time  that  the  gutta  remains  soft,  one 
makes  the  patient  speak  and  swallow,  thus  obtaining 
the  imprint  of  the  various  muscular  projections  of  the 
region.  The  cooled  and  hardened  gutta  is  pulled  out 
for  the  excess  material  to  be  removed,  then  put  back 
in  place  and  worn  by  the  patient  for  forty-eight  hours. 
At  the  end  of  this  time  the  impression,  which  is 
equally  the  rough  model  of  the  appliance,  has  become 
ready  to  a  nicety,  and  all  that  remains  is  to  make 


88  INJURIES  OF   THE  FACE  AND  JAW 

with  its  help  the  hard  rubber  piece.  Excepting  the 
impression-taking,  which  is  a  dehcate  business, 
Suersen's  apphance  is,  as  we  see,  easy  to  make, 
because  of  its  utter  simphcity. 

Third  Apparatus  of  Martin. — Suersen's  apparatus 
is  only  able  to  help  a  person  to  whom  has  been 
vouchsafed  a  superior  constrictor  powerful  enough 
to  form,  in  contraction,  a  pad  able  to  shut  off  the 
naso-pharynx.  But  the  pad  does  not  always  exist; 
in  fact,  it  seems  to  be  very  underdeveloped  in  our 
country — too  much  so,  according  to  CI.  Martin,  for 
us  to  use  Suersen's  contrivance.  CI.  Martin,  despite 
having  examined  a  host  of  patients;  only  found  this 
pad  once,  and  that  was  in  a  patient  wearing  a 
Brugger's  appliance. 

"  This  disparity  in  our  observations  is  explicable," 
he  says,  "  by  the  very  characteristics  of  the  patient's 
national  tongue.  German  is  essentially  guttural, 
and  the  pharyngeal  muscles  take  an  important  part 
in  uttering  almost  all  sounds;  so  it  is  easy  to  under- 
stand the  hypertrophy  of  these  muscles.  On  the 
contrary,  French  is  very  soft;  I  will  even  assert  that 
the  guttural  consonants  in  French  take  on  a  more 
mellow  pronunciation.  Maybe  that  is  the  reason 
which  has  led  us  to  look  for  lighter  and  more  movable 
appliances."* 

It  is  in  virtue  of  these  ideas  that  CI.  Martin  has 
simplified  his  trap-door  obturator  by  reducing  it  to 
a  completely  rigid  appliance,  in  the  same  way  as 
Suersen's.  But  this  appliance,  "  instead  of  ending 
behind  in  a  cubical  mass,  carries  here  a  simple  2  mm. 

*   Cl.   ■Martin,  Cong.  Madrid,  p.  48. 


LATE  PROSTHESIS  89 

sheet  of  rubber,  which  makes  contact  with  the 
pharyngeal  wall  at  the  level  of  the  superior  con- 
strictor. This  plate,  where  it  leaves  the  hard  palate, 
passes  above  the  stumps  of  the  velum,  and  expands 
to  the  full  width  of  the  floor  of  the  nasal  fossae. 
Thus  it  prevents  the  current  of  respired  air  from 
passing  into  the  nasal  cavity.  Fairly  thick  in  front, 
where  it  fills  part  of  the  nasal  fossae,  it  thins  out  as 
it  passes  backwards;  and  its  posterior  edge  ends  in 
a  thin  sheet  of  soft  rubber,  which  is  brought  to  bear 
on  the  pharyngeal  wall.  The  stumps  of  the  velum, 
instead  of  gliding  on  to  the  sides  of  the  appliance, 
as  in  Suersen's,  lie  slack  on  its  under-surface.  The 
apparatus  is  first  of  all  put  in  position  for  eight  or 
ten  days.  Owing  to  its  construction,  the  air  is 
obliged  to  pass  entirely  by  the  mouth,  thanks  to 
which,  at  the  end  of  forty-eight  hours,  the  patient 
begins  to  talk  fairly  well.  The  voice  is  very  pure, 
but  has  the  timbre  which  one  gets  by  closing  the 
nostrils." 

When  the  velum  stumps  are  sufficiently  used  to  the 
contact  of  the  appliance,  we  hollow  grooves  out  of 
the  latter  at  the  level  of  the  points  where  the  stumps 
will  impinge  during  their  contractions.  These 
grooves  are  prolonged  as  far  as  the  nasal  fossae  in 
such  fashion  as  to  allow  the  patient  gentle  nasal 
respiration.  After  another  trial  of  a  fortnight,  we 
increase  the  depth  of  these  grooves  which  lodge  the 
velum  stumps.  Thus  we  provide  for  the  air  current 
a  sulticient  passage  to  re-establish  nasal  respiration 
of  full  amplitude. 

At  the  moment  of  contraction  of  the  velum,   the 


go  INJURIES  OF  THE  FACE  AND  JAW 

stumps  impinge  in  the  groove  and  close  oft  all  com- 
munication with  the  nasal  fossae.  The  results  ob- 
tained by  Martin  with  this  latest  obturator  have 
been  remarkable. 

With  this  apparatus  Martin  endeavoured  to  restore 
their     physiological     functions    to    the    stumps,    by 
giving  them   a  point  d'appui.     "  The   direct   use  of 
these  stumps,"  he  says,  "  in  the  production  of  sound 
gives  to  it  a  softer  and  more  natural  quality.     It  is 
no  longer  the  appliance  which  vibrates  to  and  fro 
in  front  of  the  muscle,  but  the  muscle  which  keeps 
its  normal  play  and  simply  takes  its  support  from 
the  appliance.     In  a   very   short   time  the  muscles 
succeed  in  executing  wonderfully  their  new  function. 
Thus  by  a  similar  evolution  of  thought  I  have  arrived 
at    practically   the   same   results   as   Suersen.      The 
essential  difference  between  his  appliances  and  mine 
lies  in  this,   that,   instead  of  using   the  pharyngeal 
muscles    as    an    active    occluding    agent,    I    use    the 
muscles  of  the  velum.     In  each  apparatus,  Suerseti's 
and   mine,    the   t^'pe   is   indicated   by   the   language 
spoken  by  the  patient.     It  is  highly  probable  that 
in  Germany  my  contrivance  will  render  less  service 
than   will    Suersen's;    conversely,    Suersen's   gives   a 
poorer  result  among  patients  who  converse  in  French. 
But,  from  the  fact  that  they  allow  a  free  muscular 
play,   which  can  only  help   their  development,   the 
result  can  only  ameliorate  in  the  long-run;  for  the 
patient   is   using  muscular  mechanisms  which  grow 
and  grow  in  strength." 


LATE  PROSTHESIS  91 


III.  Prosthetic  Intervention  after  Staphylorrhaphy. 

We  have  seen  in  an  earlier  chapter  that  scar  tissue 
tends  perpetually  to  retract,  but  that  gentle  and 
continuous  pressure  succeeds  fairly  easily  in  correcting 
this  retractility. 

After  a  velo-palatine  restoration  by  staphylor- 
rhaphy/ we  see  as  a  rule  a  certain  shortening  of  the 
remade  velum,  due  to  cicatricial  retraction.  Occa- 
sionally this  retraction  is  such  that  some  functional 
disability  persists  by  reason  of  the  undue  shortness 
of  the  velum.  To  generalize,  one  may  say  that  after 
staphylorrhaphy  the  velum  is  too  short,  too  tense, 
and  made  rigid  by  cicatricial  tissue. 

Many  authors  have  tried  by  prosthetic  means  to 
cure  such  happenings,  which  rob  the  patient  of  much 
of  the  benefit  that  he  ought  to  extract  from  the 
surgical  procedure  which  he  has  undergone. 

Schiltsky's  Appliance. — This  is  inspired  by  Suersen's 
principle,  and  intended  to  remedy  the  shortness  of 
the  velum  which  is  often  apparent  in  the  train  of  a 
staphylorrhaphy.  This  appliance,  instead  of  being 
all  in  one  piece,  is  divided  into  two  parts :  a  palatine 
plate  and  a  pharyngeal  block,  joined  only  by  a 
metallic  spring  which  can  move  on  the  anterior 
surface  of  the  repaired  velum.  Thus,  the  pharyngeal 
block  comes  to  rest  between  the  posterior  surface  of 
the  velum  and  the  pharyngeal  wall.  The  palatine 
piece  is  made  of  hard  rubber.  The  impression  of  the 
pharynx  is  taken  according  to  Suersen's  process; 
and  the  pharyngeal  block  is  made  by  Schiltsky  in 


92 


INJURIES  OF  THE  FACE  AND  JAW 


gum  elastic,  so  as  to  be  slightly  compressible.  This 
substance  having  the  disadvantage  of  changing  very 
quickly,  it  would  be  preferable  to  use  soft  vulcanized 
rubber  (Fig.  65). 

Method  of  Krouschoff.— Krouschoff,*  in  1885,  was 
the  first  to  think  of  making  supple  the  velum  (created 
by  staphylorrhaphy)  by  applying  pressure  with  an 
arrangement  formed  as  follows:  A  palatine  plate  in 
hard  rubber  carries  a  prolongation  covering  the  lower 
surface  of  the  restored  velum.     A  spring  keeps  this 


Fig.   65. — Schiltsky's  Obturator. 


prolongation  on  the  velum,   thus  exercising  a  con- 
tinuous pressure  sufficient  to  obtain  its  lengthening. 

Method  of  Brugger. — Later  Bruggerf  replaced  the 
continuous  pressure  by  massage,  carried  out  several 
times  daily  for  some  minutes.  After  the  lapse  of  a 
certain    time    the    velum    gets    soft    and    elongated 

*  Krouschott,  "  Treatment  of  Palatine  Fissures  and 
Perforations  by  a  New  Method:  Staphylorrhaphy- Urano- 
plasty and  Obturators,"  St.  Petersburg,  1885. 

t  Brugger,  "Treatment  of  Palatine  Fissures:  Prosthesis 
with  a  Core  of  Cork,"  Leipzig,  1895. 


LATE  PROSTHESIS 


93 


enough  to  raise  itself  naturally.  At  the  outset  the 
patient  wears  an  appliance  of  Schiltsky  or  that  of 
-Brugger  himself,  which  difters  from  the  former  in 
that  the  pharyngeal  piece,  instead  of  being  in  gum 
elastic,  is  made  of  a  core  of  cork  surrounded  by  soft 
vulcanized  rubber.  In  proportion  as  the  velum, 
under  the  influence  of  the  massage,  lengthens  and 
becomes  supple,  Brugger  reduces  the  thickness  of  the 
pharyngeal  appliance,  and  occasionall}^  arrives  at  its 
complete  suppression  (Figs.  66  to  71).     We  do  not 


Fig.  66. — Brugger's  Obturator. 


know  enough  as  to  the  value  of  massage  to  remedy 
the  shortness  of  the  cicatricial  velum.  One  of  us 
has  demonstrated,  on  a  patient,  an  elongation  of 
10  mm. :  this  was  in  five  months  of  massage  helped 
by  orthophonic  exercises. 

Massage  is  the  necessary  complement  of  staphylor- 
rhaphy. But  that  is  an  axiom  that  is  unfortunately 
not  generally  known. 


Fig.  67. — ^Brugger's  Obturator  complete. 

a,  Palatine  plate;  b,  spring;  c,  rubber  sheath  protecting  the 
spring;  d,  obturating  part. 


Fig.  68.^The  Same  in  Transverse  Section. 
a  b 


Fig.  69. — Brugger's  Obturator  for  Cases  not  operated  on. 


LATE  PROSTHESIS 


95 


Fig.  70. — Brugger's  Obturator  for  Cases  not  operated  on. 

a  h 

c 


Fig.   71. — The  Same  in  Longitudinal  Section. 

a,  Rubber  outer  covering;  h,  core  of  cork;  c.  plate;   d.  inter- 
mediate part. 

IV.  Obturators  enabling  Newly-born  Children,  afflicted 
with  Labial  or  Palatine  Fissures,  to  be  suckled. 

The  mortality  of  nurslings  sulicring  from  con- 
genital fissure  of  lip  and  palate  is  much  raised  owing 
to  the  difficulty  of  feeding  them.     Suckling  at  the 


96  IX JURIES  OF  THE  FACE  AND  JAW 

mother's  breast  can  never  be  accomplished,  because 
prehension  of  the  nipple  is  impossible.  Suction  and 
swallowing  cannot  be  effected,  and  the  milk  is  re- 
jected by  the  nares.  To  nourish  these  infants,  we 
are  reduced  to  the  use  of  either  a  small  spoon,  a 
long  pharyngeal  teat,  or  a  stomach-tube.  Under 
such  faulty  conditions  of  alimentation,  the  majority 
of  these  infants  succumb  rapidly,  most  often  from 
the  sequelae  of  gastro-enteritis. 

Warnekros  of  Berlin  made  the  first  appliance  to 
enable  these  infants  to  suck.  This  appliance, 
wonderfully  simple,  has  given  him  the  best  results. 
He  uses  as  an  impression  tray  a  small  spoon,  and 
covers  its  convexity  with  a  little  Stent's.  The  whole 
is  introduced  into  the  mouth  and  pressed  gradually 
against  the  vault.  As  soon  as  he  has  cast  the  im- 
pression in  plaster,  he  makes  the  appliance  by  pressing 
on  to  the  model  a  leaf  of  wax,  covering  all  the  palatine 
region.  At  the  front  of  this  plate  is  fixed  a  wire 
loop.  The  whole  is  flasked.  The  wax  is  replaced 
by  rubber,  and  there  we  have  a  small  apparatus  in 
vulcanite.  It  closes  the  palatine  fissure,  and  presents 
in  front  a  loop  by  which  we  can  introduce  and  re- 
move it,  and  hold  it  in  place  during  sucking. 

One  can  make,  to  facilitate  sucking,  two  appli- 
ances, similar  except  that  the  metal  loop  is  to  the 
right  of  the  mid-line  in  one,  to  the  left  in  the  other. 
This  arrangement  is  useful  to  enable  the  mother  to 
hold  the  appliance  during  suckling  at  the  right  and 
left  breasts.  Naturally,  the  appliance  is  removed 
during  the  interval  between  feeds. 

The  feeding  of  the  infant  may  thus  be  well  carried 


LATE  PROSTHESIS 


97 


Fig.  72. — ^lartin's 
Appliance. 

A,  Soft  rubber  cushions  which 
grip  the  septum;  B,  reten- 
tion-plate which  rests  on 
the  premaxilla;  C,  artificial 
Hp  in  soft  rubber,  hollow, 
filled  with  water. 


Fig.  74.  —  Spring  passing 
through  the  Palatal  Fis- 
sure. 

A,  Soft  rubber  velum. 


Fig.  73.— Martin's  AppUance: 
Springs  passing  into  the 
Nares. 

A,  Soft  rubber  velum. 


Fig.  75. — Fixation  by  Soft 
Rubber  Pads  which  take 
their  Support  from  the 
Upper  Surface  of  the  Bony 
^Margins  of  the  Palatine 
Fissure. 

A,  Soft  rubber  yelum. 


Fig.  76. — Teat  with  Obturating  Palatine  Plate. 

A,  Prolongations  to  prevent  the  backward  displacement  of 
the  teat;  B,  ivory  ring  which  may  if  desired  repla,ce  the 
prolongations  A;  C,  palatine  plate  in  soft  rubber. 


98  IK  JURIES  OF  THE  FACE  AND  JAW 

out,  thanks  to  the  palatine  plate  giving  a  point 
d'ap'pui  for  suction  and  preventing  reflux  by  the  nose. 
CI.  and  Fr.  Martin  have  made  some  appliances 
for  the  same  purpose,  but  they  have  sought  to  obtain 
their  retention  by  taking  a  point  d'appui  from  the 
margins  of  the  fissure  and  the  walls  of  the  nasal 
fossae.  They  recommend  the  use  of  plates  of  hard 
rubber  to  cover  the  vault,  and  soft  rubber  in  the 
region  corresponding  to  the  split  velum.  This 
pliable  part  of  the  obturator  is  thus  able  to  receive, 
"  from  the  stumps  of  the  natural  velum,  light  move- 
ments, helping  a  little  to  facilitate  suction.  The 
appliance  is  kept  in  place  by  means  of  two  gold 
wires  fixed  from  the  fore  part  of  the  palatine  piece- 
From  there  these  wires  pass  out  of  the  mouth, 
describing  a  curve  to  encircle  the  upper  lip,  and  their 
free  end  enters  the  nasal  fossae  by  the  nares. 

Each  of  these  wires  carries  at  its  end  a  small  soft 
rubber  olive,  4  or  5  mm.  in  diameter;  these  increase 
the  surface  of  contact  and  make  the  pressure  more 
gentle.  Thus  they  constitute  two  springs  which 
exercise 'a  very  light  pressure  on  the  floor  of  the 
nasal  fossae,  and  so  keep  the  plate  snug  against  the 
vault. 

"  Moreover,  this  mode  of  retention  can  be  modi- 
fied," say  the  brothers  Martin,  "  to  suit  the  varieties 
and  degree  of  the  deformity.  Thus,  when  the 
palatine  vault  itself  is  fissured,  one  can  fix  the  springs 
on  the  upper  surface  of  the  appliance,  and  direct 
them  forwards  through  the  fissure.  In  another  case, 
when  the  alveolar  margin  itself  is  cleft,  one  can  put 
pads  at  the  margin  of  the  fissure;  and  the  upper 


LATE  PROSTHESIS  yy 

surfaces  of  these  pads  take  the  pressure  of  the 
springs.  Lastly,  in  some  cases,  one  will  be  able  to 
take  a  point  d'apptd  from  soft  rubber  appendages, 
which  grip  either  the  septum  itself  or  the  premaxilla, 
or  the  borders  of  the  fissure  when  these  make  a 
sufficiently  sharp  projection. 

"  Thus  the  mode  of  retention  can  vary  according 
to  the  anatomical  condition  existing  in  each  particular 
case.   ^ 

When  it  is  necessary  to  re-establish  the  continuity 
of  the  upper  lip,  Martin  has  shown  that  it  is  feasible 
to  add  to  the  palatine  piece  a  hollow  soft  rubber 
artificial  lip,  filled  with  water,  supple  enough  to  fit 
perfectly  on  to  the  lower  lip. 

The  use  of  these  prostheses  is  only  of  absorbing 
interest  when  the  child  can  be  fed  at  the  breast  of 
its  mother  or  a  nurse.  When  it  can  only  feed  from 
a  bottle,  Martin  adapts  to  the  upper  part  of  the  teat 
a  vulcanized  rubber  plate,  slightly  softened,  having 
approximately  the  form  of  the  palatal  vault.  This 
plate  provides  a  sufficient  closure  of  the  nasal  fossae, 
and  a  solid  purchase  for  the  tongue  during  the  attempt 
to  suck.  It  is  well  that  the  part  of  this  plate  which 
corresponds  to  the  velum  should  be  of  soft  rubber, 
for  the  reasons  shown  above.  Delair  also  has  made 
a  false  velum  for  the  newly-born  with  fissures;  but 
his  contrivance  is  more  complicated  than  Martin's. | 

*  CI.  and  Fr.  ]\Iartin,  "  Labio-Palatine  Prosthesis  permit- 
ting Suction  to  the  New-born  afflicted  with  Cleft  Palate  and 
Hare-Lip"  (i^rCong.  de  stomatol.,  Paris,  Aout,  1907;  Labora- 
toire,  3  Nov.,   igoy). 

f  Delair,  "  Artificial  Velum  for  the  New-born  "  (Congres 
dent,  national,  Cherbourg,  1904). 


loo  INJURIES  OF  THE  FACE  AND  JAW 

It  is  essentially  composed  of  two  parts.  One,  the 
upper  piece,  comprises  a  palatine  plate,  prolonged 
backwards,  without  a  joint,  into  a  soft  rubber  velum; 
and  the  other,  lower  piece  is  applied  to  the  alveolar 
border  of  the  mandible.  The  surface  of  these  pieces 
which  lies  against  the  mucosa  is  of  soft  rubber; 
they  have  an  artificial  alveolar  margin  of  hard 
rubber.  Some  bilateral  springs  join  the  upper  to 
the  lower  part,  and  thus  is  constituted  a  mode  of 
retention  entirely  similar  to  that  in  use  in  certain 
cases  for  complete  upper  and  lower  dentures. 

V.  Conclusions. 

What  conclusions  ought  we  to  draw  from  this 
study  of  velo -palatine  restorations  ? 

Staphylorrhaphy  evidently  constitutes  the  best 
solution  of  the  problem.  But  it  is  not  always 
possible,  nor  is  it  applicable  at  all  ages.  Surgeons 
are  agreed  in  declaring  all  intervention  at  the  level 
of  the  velum  contra-indicated  before  the  age  of  six 
to  eight  years.  Nevertheless,  Brophy*  interferes 
a  few  days  after  birth,  but  his  very  special  mode  of 
operation,  still  much  under  discussion,  has  not  come 
into  common  practice. 

Now,  prosthetic  interference  is  useful,  in  the 
majority  of  cases,  a  few  days  after  birth;  apropos 
of  this  we  have  seen  some  appliances  invented  by 
Warnekros,  CI.  Martin,  Delair,  to  facilitate  suckling 
for  infants  afflicted  with  hare-lip.     When  the  patient 

*  Brophy.  Cong.  dent,  internal. ,  1900;  vide  also  the 
general  review  of  the  question  by  Lenormant  [Presse  Med., 
28  Fevr.,  1914,  p.  167). 


LATE  PROSTHESIS  loi 

reaches  an  age  propitious  for  intervention,  staphy- 
lorrhaphy will  be  performed.  At  this  stage,  again, 
the  prosthesist  can  give  the  surgeon  invaluable  help. 
It  occurs,  as  a  fact,  in  certain  cases,  that  the  velo- 
palatine  cleft  is  considerable;  and  that  the  borders, 
too  far  separated,  do  not  allow  of  finding  in  the 
neighbouring  mucosa  enough  material  to  close  the 
fissure  and  make  a  good  junction  of  flaps.  In  the 
same  way,  sometimes  in  hare-lip  the  premaxilla 
projects  forwards,  pushing  out  the  lip  and  inter- 
rupting the  dental  arch.  A.  Ducourneau  has  reduced 
the  incisor  bud  with  the  help  of  elastic  traction, 
applied  through  the  medium  of  an  orthodontal 
apparatus  on  a  principle  analogous  to  that  applied 
every  day  for  misplaced  incisors.  He  has  shown 
how  this  prosthetic  intervention,  in  reducing  a 
skeletal  deformity,  facilitates  the  surgeon's  task. 

One  of  us,  inspired  by  the  same  ideas,  has  utilized 
the  following  apparatus  to  allow  of  surgical  inter- 
ference in  a  case  of  too  great  spreading  of  the  margins 
of  a  velo-palatine  fissure.  It  occurred  in  an  infant 
who  had  been  operated  on  by  his  professor,  M. 
Sebileau. 

Some  metal  caps  are  sealed  on  to  the  upper  molars 
of  each  side.  They  are  joined  transversely  by  a 
strand  of  rubber,  and  the  elastic  traction  of  this 
without  delay  brings  together  the  two  maxillae,  thus 
reducing  the  intervening  cleft.  It  is  even  possible 
to  bring  the  edges  of  the  palatal  fissure  entirely  into 
contact.  When  the  surgeon  deems  the  reduction 
sufficient,  he  operates  on  the  patient  and  fthe  appli- 
ance   is    removed.     Subsequently    the    two    maxillae 


I02  INJURIES  OF  THE  FACE  AND  JAW 

separate  anew,  and  the  interdental  articulation, 
temporarily  deranged,  becomes  spontaneously  re- 
stored; but  thanks  to  the  staphylorrhaphy  the 
fissure  remains  closed.  The  elasticity  which  is 
peculiar  to  scar  tissue  lends  itself  easily  to  this 
unaided  stretching. 

Such  is  the  role  of  the  dentist  before  staphylor- 
rhaphy. As  regards  after  the  operation,  we  know 
how  useful  it  can  be  in  the  event  of  cicatricial  short- 
ness of  the  velum  (Brugger,  Schiltsky,  Krouschoff); 
and  we  have  shown  the  indispensable  part  played 
by  massage,  or  by  the  lengthening  appliances  which 
supplement  massage  by  their  more  continuous  action. 

Lastly,  when  we  are  dealing  with  an  intractable 
infant  whom  it  will  be  impossible  to  keep  silent, 
operation  may  eventuate  in  catastrophe.  The  wires 
cut  through  the  mucosa,  the  stitches  loosen  gradually, 
and  the  patient  recovers  with  a  fissure  larger  than 
before  the  surgical  interference.  The  stumps  of  soft 
palate,  jagged  and  retracted,  have  now  lost,  owing 
to  scar  tissue,  their  mobility,  and  perchance  there  is 
not  enough  material  of  the  neighbouring  mucosa  left 
over  to  justify  operating  anew.  In  such  an  event, 
and  in  another  fairly  frequent,  where  an  adult  patient 
refuses  any  surgical  intervention,  it  falls  to  the  dentist 
to  treat  the  infirmity  of  the  invalid  by  prosthetic 
means.  Among  the  legion  of  false  vela  and  obtura- 
tors which  have  been  devised,  what  is  the  apparatus 
of  choice  ? 

One  should  turn  to  the  most  simple,  and  never 
lose  the  point  of  view  that  anatomical  reconstitution 
matters  little,  but  solely  functional  restoration  is  of 


LATE  PROSTHESIS  103 

advantage.     And  above  all  it  is  wise  to  answer  this 
question : 
At  what  age  should  an  obturator  he  fitted  ? 

According  to  Suersen,  we  must  wait  until  the 
ninth  or  tenth  year  to  be  able  to  use  as  point  d'appui 
the  first  permanent  molars.  Previous  to  this,  the 
deciduous  molars  give  no  adequate  support.  Par- 
kinson puts  back  the  age  to  fourteen  or  sixteen  years 
as  favourable  for  applying  apparatus.  The  prospects 
of  success  are  so  much  the  greater  as  the  child  is 
more  developed  and  intelligent. 

At  a  too  tender  age  prostheses  give  less  satisfaction 
as  regards  speech.  But  this  d®es  not  apply  from  the 
point  of  view  of  feeding.  The  babies,  not  being 
irritated  by  their  eating  and  drinking,  feed  nor- 
mally, and  one  sees  puny  children  develop  in  an 
amazing  fashion.  Speech  cannot  be  ameliorated 
until  later  on,  when  the  infant  can  be  put  through 
an  orthophonic  training. 

The  obturator  of  CI.  Martin  or  that  of  Suersen 
are  the  contrivances  of  choice.  They  are  simple, 
very  easy  to  make,  inexpensive,  and,  above  all,  they 
can  be  altered  by  the  orthophonist  during  the  actual 
course  of  the  patient's  training.  There  we  have  a 
consideration  too  often  neglected  among  people  who 
have  to  decide  on  the  choice  of  a  suitable  appliance. 
In  fact,  we  must  not  forget  that,  from  the  point  of 
view  of  functional  results  (at  any  rate,  as  far  as 
speech  is  concerned),  the  role  of  surgeon  or  pros- 
thetist  has  not  the  decisive  importance  which  people 
are  often  pleased  to  accord  them. 

An  infant  is  the  victim  of  a  congenital  fissure  of 


I04  INJURIES  aF  THE  FACE  AND  JAW 

the  soft  palate.  We  operate;  his  velum  is  remade, 
but  for  that  matter  he  speaks  not  much  more  correctly 
than  before  the  operation.  This  velum  made  sur- 
gically is  in  very  truth  an  artificial  one.  It  does 
not  escape  the  laws  which  govern  all  cicatricial  tissue : 
it  retracts  and  becomes  shorter.  This  soft  palate  is 
admittedly  restored  in  its  anatomy,  but  not  in  its 
function;  it  is  nothing  but  a  fibrous  sheet,  robbed  of 
suppleness  and  real  mobility. 

The  patient  operated  on  will  not  derive  a  true 
and  complete  benefit  from  the  procedure  unless  he 
is  placed  in  the  hands  of  a  competent  orthophonist. 
This  latter  by  frequently  repeated  massage  will 
lengthen  and  make  flexible  the  velum  reconstructed 
by  the  surgeon.  And  he  will  teach  the  patient,  by 
means  of  painstaking  and  progressive  exercises  of  the 
pharyngeal  muscles,  to  help  himself  to  speak.  Simi- 
larl}',  if  for  one  reason  or  another  we  have  declined 
against  operation  for  a  congenital  cleft  palate,  the 
patient  \Vill  not  be  enabled  to  speak  merely  because 
a  prosthesist  has  fitted  a  false  velum,  no  matter 
how  ingenious  and  well  thought  out  it  be.  An 
orthophonist  will  have  to  teach  the  invalid  to  make 
good  use  of  the  prosthesis  which  he  has  given  him. 

Now,  exercises  for  the  pharyngeal  muscles  and 
pillars  stimulate  their  development,  which  is  in- 
creased by  the  ridges  made  by  these  muscles  beneath 
the  mucosa.  To  such  an  extent  does  this  occur  that 
at  the  end  of  a  few  weeks,  an  obturator  which  at 
the  outset  exactly  corresponded  to  neighbouring 
pharyngeal  surroundings  soon  ceases  to  fit  them 
properly.     The  orthophonist  must  be  able  to  change 


LATE  PROSTHESIS  105 

this  obturator  in  its  pharyngeal  part  in  proportion 
to  the  muscular  development  which  is  taking  place 
in  his  subject.  Thus,  he  should,  for  instance,  with 
Suersen's  appliance,  now  and  again  soften  in  warm 
water  the  gutta-percha  ball  which  obstructs  the 
pharynx,  so  that  the  pharyngeal  muscles  may  be 
able  to  imprint  on  this  ball  the  depressions,  for  ever 
growing  deeper  and  deeper,  which  they  make  along 
its  outer  surface.  When  the  education  of  the  sub- 
ject is  finished,  when  his  complete  muscular  develop- 
ment has  been  obtained,  only  then  can  one  substitute 
for  the  gutta  ball  a  final  obturator  of  vulcanized 
rubber.  Moreover,  there  again  it  is  the  orthophonist 
who  decides  as  to  when  the  prosthesist  shall  inter- 
vene; for  the  latter  must  only  provide  that  instru- 
ment which  the  former  orders  and  says  shall  be 
used.  Lack  of  understanding  of  this  indispensable 
collaboration  has  involved  various  handicaps,  and  is 
probably  the  cause  responsible  for  the  enormous 
multiplicity  of  divers  types  of  apparatus.  We 
blame  the  apparatus  for  not  yielding  results,  we  hunt 
for  modifications,  improvements,  complications, 
meanwhile  usually  forgetting  to  teach  the  patient 
to  use  it. 

"  When  an  obturator  has  been  placed  with  every 
possible  care,  and  fulfils  its  purpose  in  perfect  style; 
the  subject  who  has  never  spoken  speaks  no  better ; 
on  the  contrary,  his  speech  is  often  worse.  It  is 
necessary  for  the  patient  to  undergo  a  special  educa- 
tion, so  that  all  the  parts  of  the  mouth  come  to  get 
used  to  the  contrivance;  for  we  know  that  all  the 
muscles  of  the  soft  parts  co-ordinate  in  phonation 


io6  INJURIES  OF  THE  FACE  AND  JAW 

and  in  the  articulatiori  of  sounds.  Now,  they  cannot 
suddenly  execute  movements  which  up  to  date  they 
have  never  made  "  (Preterre). 

This  is  equally  true  of  persons  who  have  under- 
gone staphylorrhaphy.  The  methods  in  vogue  at 
the  present  day  for  teaching  the  faculty  of  speech 
to  the  deaf  and  dumb  render  under  such  circum- 
stances excellent  service.  But  they  are  in  use  quite 
rarely  in  France  for  cleft  vela,  whether  the  subject 
has  been  operated  on  or  wears  an  appliance.  Abroad, 
notably  in  Germany  and  Switzerland,  there  is  a  real 
speciality  of  this  nature;  and  a  few  schools  for  the 
deaf  and  dumb  have  classes  entirely  formed  of 
patients  operated  on  or  wearing  apparatus. 

One  of  us  has  been  able  to  demonstrate  remarkable 
results  thus  obtained  at  the  national  institute  for  the 
deaf  and  dumb  at  Moudon  (Switzerland).  Phonetic 
training,  according  to  the  age  of  the  subjects,  lasts 
for  from  three  to  six  months.  It  would  seem  that 
similar  instruction  could  be  obtained  in  our  French 
deaf-and-dumb  schools,  if  all  surgeons  and  pros- 
thesists,  convinced  of  the  paramount  importance  of 
this  stage  of  treatment,  S3^stematically  sent  their 
patients,  post-operative  and  wearers  of  appliances, 
to  do  their  phonetic  training  there.  As  a  fact,  it  is 
rarely  that  the  prosthesist  possesses  simultaneously 
the  time  and  the  practical  knowledge  of  orthophonia 
necessary  to  bring  this  education  to  a  happy  ending.* 

*  Delair.  "  Principles  of  Phonetics  and  Orthology  "  (Cong, 
dent,  nat.,  Montaiiban,  Aoiit,  1902;  OdontoL,  30  Juillet,  1902, 
p.  184). 


LARYNGEAL  PROSTHESIS  107 

CHAPTER  IV 

LARYNGEAL  PROSTHESIS 

Billroth  was  the  first  to  practise  total  ablation  of 
the  larynx,  and  his  pupil  Gussenbauer  invented  the 
first  artificial  larynx  which  has  been  substituted  for 
the  organ  removed.  After  him  von  Bruns,  Foules, 
Labbe  and  Cadier,  and  Julius  Wolff,  brought  various 
improvements  to  bear  on  this  special  prosthesis. 
Aubry,  instead  of  using  the  current  of  air  expired 
by  the  lungs,  availed  himself  of  air  expressed  by 
means  of  a  bulb  compressed  by  the  hand.  Hochenegg 
used  a  bellows  placed  against  the  chest  and  pressed 
by  the  arm.  Gliick  and  Stork  conducted  the  vibra- 
tions into  the  pharyngeal  cavity  by  means  of  a  long 
tube  penetrating  the  nose  or  the  mouth. 

"  From  that  time,"  says  CI.  Martin,  "  these  in- 
struments were  talking  machines  much  more  than 
true  artificial  larynxes,  not  conforming  in  principle 
and  execution  to  the  rules  laid  down  by  Gussen- 
bauer."* The  apparatus  of  Gliickf  consists  of  a 
rubber  tube  which  fits  by  one  end  into  the  tracheal 
cannula,  and  by  the  other  passes  in  by  one  of  the 
nostrils,  as  far  as  the  pharynx.  The  vibrating 
apparatus  is  put  at  the  orifice  of  the  cannula;  it 
comprises  a  metal  tube  pierced  by  a  window.     The 

*  CL  Martin,  "  On  Artificial  Larynges  "  [Odontologie, 
30  Sept.  et  15  Oct.,  1902). 

f  Gliick,  "  Total  Extirpation  of  the  Larynx,  and  the  Use 
of  Special  Prostheses"  {Monatschr.  fiir  Ohrenheilk.,  t.  xxxviii., 
No.  3,  et  Cong,  internat..  de  laryngo-rhinologie,  Vienne, 
21-25  Avril,  1908;  Pyesse  MH.,  6  Mai,  1908,  p.  254). 


io8  INJURIES  OF  THE  FACE  AND  JAW 

window  is  closed  by  a  very  light  valve.  At  the 
moment  when  the  patient  wants  to  speak,  he  adjusts 
the  appliance  on  to  the  cannula.  Inspiration  lifts 
the  valve  and  lets  the  air  enter  into  the  trachea, 
expiration  closes  the  valve  and  the  air  is  driven  back 
into  the  tube;  here  it  encounters  a  thin  rubber  band 
which  makes  it  vibrate. 

The  sound  produced  is  projected  into  the  pharynx, 
where  it  is  changed  into  articulate  speech.  "  This 
external  appliance,"  says  M.  Delair,  "  is  able  to 
render  great  service  to  those  who  wear  tracheotomy- 
tubes,  but  the  sound  obtained  is  necessarily  very 
feeble.  Moreover,  there  are  certain  articulate  sounds 
which,  to  be  emitted  into  the  cavity  of  buccal  re- 
sonance, require  the  normal  complete  occlusion  of 
the  naso-pharynx.  These  are,  however,  now  pro- 
duced, on  leaving  the  tube,  in  the  back  part  of  the 
nasal  fossae  and  in  the  maxillary  antra,  because  the 
postero-superior  surface  of  the  velum,  lying  against 
the  wall  of  the  pharynx,  opposes  their  passage  into 
the  buccal  cavity.  They  have  then  a  muffled  timbre 
and  are  not  very  comprehensible."* 

We  owe  it  to  Julius  Wolff  that,  following  von 
Bruns,  he  has  brought  some  true  improvements  to 
bear  on  the  construction  of  artificial  larynxes.  He 
has  made  it  practically  impossible  for  mucus  and 
saliva  to  get  into  the  apparatus,  which  allows  it  to 
work  without  interruption  for  an  entire  day.  Wolff 
arrived  at  this  result  by  closing  the  pharyngeal 
cannula  with  a  sieve  which  resisted  the  passage  of 

*  Delair,  "  Artificial  Larynx  and  Glottis"  {Odontologie, 
15  Sept.,  1904). 


LARYNGEAL  PROSTHESIS  109 

solid  or  viscous  substances;  but  when  at  meals  it 
was  obligatory  to  block  this  cannula  with  a  special 
cork,  as  in  von  Brun's  appliance. 

Michaels'  Artificial  Larynx.* — The  apparatus  con- 
sists of  three  parts :  a  tracheal  cannula,  an  oesophageal 
catheter,  and  two  ensheathing  tubes  to  hold  them. 

"  The  cannula  has  a  diameter  of  8  mm.,  and  a 
length  of  10  cm.  On  each  side  of  its  free  end  it 
carries  two  small  metal  cylinders,  vertical  and 
parallel,  i  cm.  in  diameter,  3  cm.  long.  The  upper 
ends  of  these  cylinders  are  open.  Of  the  lower  ends, 
the  left  is  closed,  the  right  has  a  lateral  window  by 
which  the  outer  air  can  enter  freely.  Behind  these 
small  cylinders  the  cannula  carries  an  expanded 
flange  resembling  that  of  the  ordinary  tracheotomy 
cannula;  and  the  lateral  wings  of  the  flange  are 
fenestrated  for  tying  on  the  cords  which  are  used  to 
fix  it  behind  the  neck. 

"The  cegophageal  catheter  is  of  red  rubber;  it  is 
largest  at  its  upper  end,  of  which  the  funnel-shaped 
mouth  is  2  cm.  in  diameter;  while  the  lower  end, 
destined  to  be  buried  in  the  oesophagus,  is  a  cylinder 
of  I  cm.  diameter.     Its  total  length  is  30  cm. 

"  The  third  piece,  which  is  likewise  of  rubber,  is 
intended  to  join  the  first  two  and  permit  of  their 
use.  It  is  made  so  as  to  facilitate,  on  the  one  hand, 
the  passage  of  air  from  the  trachea  into  the  nasal 
fossae,  and,  on  the  other  hand,  the  transit  of  fluids 
introduced  into  the  mouth  through  the  oesophageal 
catheter  so  as  to  reach  the  stomach.     To  fill  this 

*  ^Michaels,  Congres  dentaire  international  de  Nancy, 
Aout,  1896. 


no  INJURIES  OF  THE  FACE  AND  JAW 

double  purpose  by  means  of  a  single  piece  of  ap- 
paratus, it  was  essential  that  this  piece  itself  should 
possess  two  conduits,  one  for  the  passage  of  air,  the 
other  for  the  flow  of  liquids.  Let  us  begin  by  de- 
scribing the  part  which  enables  the  tracheal  air  to 
arrive  in  the  nasal  fossae.  For  this  purpose,  the 
lower  part  of  the  piece  is  made  up  of  two  rubber 
tubes,  of  which  the  lower  ends  engage  by  a  joint 
which  slides  up  and  down  in  the  upper  half  of  the 
small  cylinders  placed  each  side  of  the  tracheal 
cannula.  By  their  other  end  they  are  firmly  welded 
on  each  side  of  the  larger  tube,  which  we  shall  describe 
presently.  These  two  rubber  tubes  are  naturally 
more  narrowed  at  their  lower  free  end  than  at  their 
upper  fixed  part.  Since  the  lower  ends  are  engaged 
for  2  cm.  in  the  cylinders  placed  on  each  side  of  the 
cannula,  it  follows  that  in  this  way  they  are  im- 
movable, and  that  they  in  turn  serve  as  a  point 
d'appui  for  the  piece  on  which  they  are  grafted. 
The  principal  piece  consists  of  a  vertical  cylinder 
20  cm.  long  and  i"5  cm.  in  diameter,  of  which  the 
lower  conical  end  plunges  into  the  oesophageal  tube. 
The  body  of  the  latter  carries  on  its  anterior  surface, 
above  the  point  where  the  two  small  tubes  previously 
described  are  fixed,  a  buttress  i  cm.  square,  whose 
upper  end  is  obliquely  bevelled. 

"  This  principal  vertical  cylinder  has  inside  it  a 
tube  of  the  same  size  as  those  which  are  coupled  to 
its  sides.  This  smaller  tube,  soldered  along  the 
posterior  wall  of  the  greater  which  contains  it,  is 
also  itself  vertical  for  the  greater  part  of  its  length. 
Above,  it  projects  5  cm.  from  the  outer  tube.     Below, 


LARYNGEAL  PROSTHESIS 


III 


the  inner  traverses  the  left  side  of  the  outer  exactly 
at   the  level  where  the  outer  left   lateral  tube  has 


Fig.   77. — Artificial  Larynx  of  Michaels. 


been  grafted.  Since  the  little  tubes  are  grooved  for 
their  whole  length,  and  continued  uninterruptedly,  it 
follows  that  they  pass  across  the  ensheathing  outer 


112  INJURIES  OF  THE  FACE  AND  JAW 

tube;  and  that  they  serve  to  give  passage  to  air 
from  the  trachea  to  the  nasal  fossae,  or  vice  versa. 
On  the  other  hand,  the  large  ensheathing  tube  is 
destined  to  allow  fluids  from  the  mouth  to  enter  the 
oesophageal  catheter.  To  insure  the  passage  of  air, 
it  was  necessary  that  the  metal  C34inder  placed  to 
the  left  of  the  cannula,  into  which  the  small  rubber 
tube  enters  with  an  up-and-down  motion,  should  be 
perforated,  as  well  as  the  tracheal  cannula  at  the 
level  of  their  contact.  This  orifice  of  communication 
is  oblong,  with  a  diameter  of  5  mm.  In  order  that 
the  bronchial  air  should  penetrate  the  nasal  fossae, 
the  tracheal  opening  has  necessarily  to  be  closed. 
This  is  easily  achieved  by  a  rubber  valve. 

"  This  arrangement  of  the  apparatus  allows  the 
patient  free  respiration.  But  since,  despite  the  large 
size  of  the  tracheal  cannula,  bronchial  mucus  blown 
through  may  fill  it  up,  M.  Michaels  removed  also  a 
piece  of  the  right-hand  small  cylinder,  making  its 
lumen  communicate  with  that  of  the  cannula.  This 
communication  was  made  by  a  round  window  on 
the  outer  and  another  window  on  the  inner  aspect 
of  this  little  cylinder.  Air  enters  at  this  level  into 
the  tracheal  cannula,  by  pushing  back  a  movable 
metal  valve  inside  the  cylinder.  This  valve,  with  a 
thickness  of  i  mm.,  is  fixed  transversely  in  the  right- 
hand  cylinder.  At  rest  it  remains  thus;  during  an 
inspiratory  movement  it  is  elevated.  The  opening 
of  the  large  ensheathing  tube  corresponds  very 
accurately  to  the  base  of  the  tongue  and  the  level 
of  the  epiglottis,  so  that  at  the  moment  of  swallowing 
liquids    pass    in    without    obstruction.     The    upper 


LARYNGEAL  PROSTHESIS  113 

orifice  of  the  ensheathed  tube  ascends  the  whole 
length  of  the  posterior  pharyngeal  wall  as  far  as  the 
median  septum  of  the  nasal  fossae,  in  such  a  way 
that  the  mucus  secreted  by  the  latter,  as  also  liquids 
from  the  mouth,  cannot  enter  it.  As  for  fluids 
coming  from  the  bronchi,  they  exit  at  will  by  the 
anterior  opening  of  the  tracheal  cannula,  and  are 
collected  in  a  small  rubber  bag  placed  in  front  of  it. 
This  bag  is  itself  provided  with  a  special  opening. 
In  front  this  opening  is  tailed  off  like  a  movable 
tongue,  and  this  serves  to  close  the  opening  of  the 
tracheal  cannula  during  inspiration;  whereas  it 
allows  itself  to  be  bent  open  by  the  sputum  which 
falls  into  the  bag  during  efforts  at  spitting." 

Artificial  Larynx  of  CI.  Martin. — To  CI.  Martin  falls 
the  honour  of  having  devised  a  false  larynx  which 
acts  continuously,  and  simultaneously  allows  the 
passage  of  liquids  and  mucus  from  the  pharyngeal 
sound-box  into  the  oesophagus. 

The  parient  thus  succeeds  not  only  in  speaking 
clearly,  but  also  in  drinking  and  eating  with  the 
appliance  in  place,  and  without  having  to  pull  out 
the  sound-tube  and  plug  the  pharyngeal  part.  With 
a  happy  application  to  the  larynx  of  his  system  of 
immediate  prosthesis  (already  used  with  such  success 
for  the  lower  jaw),  CI.  Martin  fixes  in  the  wound, 
soon  after  operating,  a  temporary  appliance:  the 
size  of  this  is  approximately  that  of  the  larynx 
removed. 

This  apparatus,  as  a  sort  of  substitute  for  the 
larynx,  resists  cicatricial  contraction  during  repair, 
and  enables  one  to  prevent  the  stenosis  which  is  fatal 

8 


114  INJURIES  OF  THE  FACE  AND  JAW 

to  success.  Thanks  to  this  temporary  apphance, 
which  is  a  true  "  immediate  prosthesis  "  of  the 
larynx,   one  can  preserve  until  healing  is  complete 


D-     s 


Fig.  78. — Martin's 
Apparatus. 

A,  Resonance  box;  B,  ter- 
minal sleeve ;  C,  wire  gauze ; 
D,  oesophageal  tube ;  E,  tra- 
cheal cannula;  F,  bearing 
ring  ol  the  tracheal  can- 
nula and  the  false  larynx; 
G,  valve  sleeve  closing  the 
front  of  the  cannula;  H, 
valve;  I,  fixation  ring  of 
the  cannula. 


Fig.  79. — The  Various  Parts 
of  the  Apparatus  assembled. 
(The  terminal  sleeve  and 
the  posterior  plate  have 
been  removed.) 

A,  Resonance  box;  B,  vibrat- 
ing mouthpiece;  C,  oeso- 
phageal tube;  D,  tracheal 
cannula ;  E,  bearing  ring. 


the  necessary  space  for  the  final  apparatus.  This 
Jatter  should  only  be  substituted  for  the  provisional 
one  when  the  wound  is  completely  epithelialized. 


LARYNGEAL  PROSTHESIS 


"5 


The  artificial  larynx  of  CI.  Martin,  the  first  which 
really  deserves  this  name,  is  comprised  as  follows:* 

1.  A  tracheal  cannula  on  which  is  fixed  the  sound- 
apparatus,  by  means  of  a  ring  pierced  by  the  cannula. 

2.  The  sound-apparatus,  formed  of  three  parts: 
{a)  A  resonance  box  of  nearly  the  same  volume  as 

the  normal  larynx,  but  flattened  antero-posteriorly. 


Fig.  8o. — A,  Resonance  box 
seen  from  behind ;  B,  sleeve 
which  closes  it  at  the  top; 
C,  wire  gauze;  D,  posterior 
closing  plate. 


Fig.  8i. — A,  Vibrating  mouth- 
piece; B,  its  metal  support; 
C,  rubber  flaps  forming  a 
valve  which  opens  during 
aspiration ;  D,  fixation  wing. 


This  box  is  covered  on  the  top  by  fine  wire  gauze, 
to  prevent  the  entrance  of  solid  particles  into  the 
box. 

(&)  A  vibrating  mouthpiece  mounted  in  a  metal 
tube  which  is  rectangular  on  section.  This  presents 
on  its  front  and  back  surface  rubber  flaps,  forming 
a  valve,  which  opens  during  inspiration  and  close.! 
during  expiration.     Thus  the  whole  of  the  expired 

*  CI.  Martin,  "  On  Artificial  Larynges  ''  {Odontologie, 
30  Sept.  et  15  Oct.,  1902). 


ii6 


INJURIES  OF  THE  FACE  AND  JAW 


air  current  is  compelled  to  pass  into  the  vibrating 
mouthpiece.  This  consists  of  a  thin  rubber  tube 
stretched  transversely,  and  therefore  flattened  antero- 
posteriorly.  Its  upper  lips  limit  a  transverse  slit, 
25  mm.  long,  and  they  impart  to  the  sound  emitted 
great  power. 

(c)  An  oesophageal  tube  which  leaves  the  posterior 
wall  of  the  resonance  box  at  its  lowermost  point 
and  slopes  downwards.  The  angle  which  at  its 
origin  it  forms  with  the  resonance  box  bestrides  the 
tracheo-oesophageal  spur,  and  so  it  passes  into  the 
oesophagus. 


Fig.  82. — Rubber  Sleeve  shut- 
ting off  the  Larynx  from 
Above  and  supporting  the 
Wire  Gauze  B. 


Fig.  83. — Closing  Plate  of  the 
Posterior  Face  of  the  Outer 
Envelope  of  the  Larynx. 


[Note  by  Translator. — The  tracheo-oesophageal  spur 
is  not  a  structure  of  normal  anatomy.  The  author 
signifies  the  thickened  transverse  ridge  which  marks 
the  uppermost  limit  of  the  remains  of  the  party  wall 
between  oesophagus  and  air-passages.  This  repre- 
sents the  upper  edge  of  the  posterior  surface  of  the 
trachea,  if  the  cricoid  cartilage  has  been  removed. 
If   not,    it   will  be   the   scarred   upper    end    of    the 

cricoid.] 

At  its  lower  end  this  tube  is  cleft  into  a  double 
beak,  which  forms  a  valve  and  resists  the  passage  of 


LARYNGEAL  PROSTHESIS 


117 


fluids  into  the  artificial  larynx  during  regurgitation 
or  vomiting. 

A  supple  rubber  collar  encircles  the  pharyngeal 
part,  and,  fitting  against  neighbouring  structures, 
prevents  the  stagnation  of  fluids  around  the  ap- 
paratus and  directs  them  into  the  oesophagus  (Figs. 
81  to  84). 

Martin's  artificial  larynx  is  an  incomparable 
advance,  in  that  it  offers  the  following  advantages: 


The  Valve  Box. 


1.  It  allows  patients  to  inspire  easily  by  the  mouth 
and  nose.  The  inspired  air  current  traverses  the 
wire  gauze,  and  throws  widely  open  the  rubber  flaps 
of  the  rectangular  tube  which  contains  the  vibrating 
mouthpiece. 

2.  It  allows  the  invalid  to  drink  and  eat  without 
touching  his  apparatus,  and  consequently  to  converse 
at  meals.  Actually,  at  the  instant  of  swallowing, 
solid  substances  are  held  up  by  the  wire  gauze. 
Liquids  fall  through  this  into  the  resonance  box,  but 


ii8  INJURIES  OF  THE  FACE  AND  J  A  IV 

not  into  the  vibrating  mouthpiece,  for  its  Hps  are 
closed;  moreover,  it  is  isolated  in  the  middle  of  the 
box.  They  therefore  flow  together  into  the  sloping 
part  of  the  box,  and  are  there  caught  in  the  oeso- 
phageal tube,  which  guides  them  to  the  gullet.  As 
a  result  the  trachea  is  sheltered  from  any  entrance 
of  foreign  bodies. 

Delair's  Apparatus. — The  larynx  of  CI.  Martin  is 
indicated  subsequent  to  a  laryngotomy,  performed  on 
classical  lines,  in  which  the  prosthesist  finds  himself 
confronted  with  a  wound  which  communicates,  above 
with  the  pharynx,  below  with  the  oesophagus  and 
trachea. 

This  communication  of  the  wound  with  the  septic 
neighbourhood  of  the  pharynx,  consecutive  to  a  total 
ablation  of  the  larynx,  can  involve  serious  infectious 
sequelae,  to  which  the  patients  frequently  succumb. 

To  get  rid  of  infection,  M.  Sebileau*  has  introduced 
into  the  operative  technique  of  laryngectomy  some 
important  modifications.  He  exerts  himself  in  par- 
ticular, in  order  to  shelter  it  from  infection,  in  isolat- 
ing the  trachea  by  remaking  for  the  pharynx  an 
anterior  wall. 

There  is,  then,  no  scope  for  the  idea  that  an  im- 
mediate prosthesis  can  prepare  the  ground  for  an 
artificial  larynx,  such  a  conception  being  opposed  to 
that  of  Sebileau's  operation.  For  he,  on  the  con- 
trary, strives  to  prevent  finally  any  communication 
between  mouth  and  trachea.  Thus,  the  prosthesist 
finds  himself  compelled,   in  order  to  guide  the  air 

*    Sebileau,    "  Total    Laryngectomy  "    (Soc.    de    Chir.,    20 
Juillet,  1904). 


LARYNGEAL  PROSTHESIS 


119 


stream  from  the  trachea  into  the  mouth,  to  use  a 
conduit  which  is  artificial  and  of  necessity  external. 

Gliick's  appliance  could  render  service  in  such  a 
case,  but  it  has  the  drawback  of  giving  a  very  feeble 
sound,  and  of  directing  it  into  the  naso-pharynx, 
which  entails  a  most  faulty  articulation.     Dclair  has 


Fig.  85. — Delair's  Apparatus  assembled. 

provided  an  elegant  solution  to  this  problem  in 
prosthesis  by  devising  the  ingenious  appliance  which 
he  calls  an  "  artificial  glottis  "*  (Fig,  85). 

Delair's     appliance     consists     of     three    principal 

*  L.  Delair,  "  Artificial  Larynx  and   Glottis"  [Odontologie, 
15  Sept.,  1904). 


I20  INJURIES  OF  THE  FACE  AND  JAW 

elements:  one  external,  the  tracheal  valve  box;  and 
two  intrabuccal,  the  palatine  piece  and  the  artificial 
glottis. 


#M^^^ 


U. 


Fig.  86.— Rubber  Bird-Call. 


I.  The  valve  box  is  of  metal.     It  is  rectangular, 
and   encloses   a   flap   of   very  thin   rubber.     On   its 


Fig.   87. — Comprehensive  View  of  the  Palatine  Apparatus 

of  Delair. 

posterior  wall  is  soldered  a  tube,  fitting  exactly  into 
the  tracheal  cannula,  for  admitting  air  into  the 
lungs.    On  its  anterior  wall  is  arranged  a  rectangular 


LARYNGEAL  PROSTHESIS 


121 


opening,  behind  which  the  rubber  flap  is  stretched 
like  a  curtain.  Through  this  opening  the  air  enters  the 
box,  and  from  there  into  the  trachea.  The  upper  wall 
of  this  box  bears  a  tube  to  carry  the  air  to  the  palatine 
piece;  the  lower  wall  is  pierced  by  a  hole,  closed  b}'  a 
cork,  with  the  object  of  facilitating  cleansing. 

At  each  inspiration  the  air  raises  the  flap  placed 
on  the  anterior  wall  of  the  box  and  penetrates  the 
tracheal  cannula.  On  expiration  the  flap  closes  the 
anterior  opening,  and  the  air  escapes  by  the  upper 
tube.     This   latter   supports   a   rubber   tube   which, 


!iih:;'!!i;''i"'iii!i 


li^^ii:-':;:'! 


,i;;rn,!i;,,„ 


Fig.   88.— Metal  Grill. 


passing  up  the  neck  and  encircling  the  jaw,  adapts 
itself  to  the  palatine  appliance  at  the  level  of  the 
labial  commissure. 

2.  The  palatine  appliance  (Fig.  88),  also  of  metal, 
consists  of  two  plates  soldered  together  along  their 
border.  Between  these  plates  is  arranged  a  space, 
oval  on  section,  a  sort  of  flattened  tube,  which  ends 
on  each  side  opposite  the  first  molar.  A  welded  tube 
is  screwed  on  to  one  of  these  ends,  and  by  the  other 
fits,  opposite  to  the  labial  commissure,  on  to  the 
rubber  tube,  which  places  it  in  connection  with  the 
valve  box  above  described.  This  metal  palatine 
plate  is  kept  in  place  in  classical  fashion  by  a  certain 
number  of  hooks  gripping  the  teeth  on  either  side. 


122  INJURIES  OF  THE  FACE  AND  JAW 

The  flattened  tube  (which  traverses  it  in  the  form  of 
a  very  obtuse  V  opening  forwards)  presents  at  its 
apex  an  opening.  This  opening  is  placed  in  the  centre 
of  the  posterior  border  of  the  palatine  piece,  and  on 
it  is  fixed  the  artificial  glottis. 

3.  The  artificial  glottis  (Fig.  87)  comprises  a  rubber 
bird-call.  This  bird-call  is  composed  of  a  metal 
guide  in  the  form  of  a  crescent,  enveloped  in  a  piece 
of  very  thin  rubber  tubing.  At  its  posterior  part  is 
soldered  an  oval  tube,  for  the  fitting  of  the  piece  into 
the  corresponding  opening;  fashioned  in  the  palatine 
plate.  The  two  branches  of  the  guide  spread  open 
the  rubber  bird-call,  of  which  the  two  lips  remain  in 
close  contact. 

The  current  of  air  sent  by  the  patient  into  the 
appliance  separates  the  lips  of  the  bird-call  more  or 
less,  and  puts  them  into  vibration,  thus  producing  a 
sound  of  varying  intensity.  The  sound  produced  is 
directed  towards  the  pharynx,  and  from  this  sound 
the  organs  of  speech  evolve  words. 

The  lips  of  the  bird-call,  being  in  intimate  contact, 
resist  the  penetration  of  food  into  the  apparatus. 
This  enables  the  subject  to  eat  without  discarding 
his  palatine  plate.  But  to  this  appliance  for  produc- 
ing sound  is  supplemented  a  protective  appliance, 
meant  to  spare  the  former  from  the  compression  to 
which  it  will  be  subjected  by  the  velum  behind  and 
the  tongue  in  front.  This  protective  appliance  con- 
sists, on  its  palatine  aspect,  of  a  convex  metal  plate 
articulated  with  the  posterior  edge  of  the  palatine 
plate,  and  kept  against  the  mucosa  by  the  traction 
of  a  light  rubber  band. 


LARYNGEAL  PROSTHESIS  123 

On  the  lingual  aspect  the  protection  of  the  bird- 
call is  assured  by  a  tiny  metal  grill  fixed  on  to  the 
borders  of  the  palatine  plate.     Such  is  the  apparatus 
invented  by  Delair*  for  those  who  have  undergone 
ablation  of  the  larynx  by   Sebileau's  method.     An 
identical   arrangement   may   be   just    as   well   fitted 
to    tracheotomized   patients   who    become    aphonic. 
Delair's  scheme  offers  the  paramount  advantage  of 
placing  the  sonorous  appliance  deeply,  on  the  pos- 
terior margin  of  the  velum,  at  the  boundary  of  the 
buccal   and   pharyngeal   cavities.     Thus,    it    enables 
those  whose  larynx  has  been  ablated  to  articulate 
the  sounds  que,  ke,  gue,  x,  e,  which  cannot  be  emitted 
unless  the  sound  produced  by  the  glottis  explodes 
(after   being    checked   in   the    bucco-pharynx)    in    a 
resonance  chamber  bounded,  in  front  by  the  base  of 
the  tongue  touching  the  raised  velum,  and  behind  by 
the  pharyngeal  wall.     "  It  is,  then,  indispensable," 
says  Delair,|  "  to  place  the  artificial  glottis  as  remote 
as  possible,  to  obtain  the  same  phonetic  results  as 
with  the   human  larynx.     For  in   the   case   of   the 
latter  the  sound  reaches  the  pharynx  from  below 
upwards,    whereas   that    of   the    artificial   glottis    is 
projected  from   above  downwards  and  from  before 
backwards.     The  sound  thus  obtained  varies  accord- 
ing to  the  dimensions  given  to  the  guide  of  the  bird- 
call.     In   fact,  the   longer  the  lips  of  the  '  glottis,' 
the  deeper  the  note.     It  falls  to  the  prosthesist  to 
adjust  the  tension  of  the  bird-call  so  as  to  give  a 

*    Delair,    "Artificial    Larynx    and    Glottis"    {Odoniologie, 
15  Sept.,  1904). 
t  Ibid. 


124  INJURIES  OF  THE  FACE  AND  JAW 

voice  timbre  consistent  with  the  age,  sex,  strength, 
and  vocation,  of  his  patient." 

The  wearing  of  Delair's  apparatus  is  subordinated 
to  the  education  of  the  palate  reflexes.  This  educa- 
tion is  obtained  in  a  few  weeks  with  the  aid  of  rubber 
appliances;  these  are  made  progressively  more  and 
more  crescentic  in  shape,  and  soon  engender  a  perfect 
tolerance. 

Delair's  appliance  is  contra-indicated  in  a  patient 
whose  trachea  has  not  been  shut  off  from  the  hypo- 
pharynx,  the  meeting-place  of  the  respiratory  and 
digestive  tracts.  In  such  a  case  CI.  Martin's  con- 
trivance gives  better  results.  In  other  respects  these 
two,  appliances  are  not  divergent,  since  each  is 
destined  for  a  different  type  of  patient.  And  their 
respective  indications  are  drawn  from  the  method 
which  has  been  followed  in  the  laryngectomy  which 
they  are  to  ameliorate. 


CHAPTER  V 
LINGUAL  PROSTHESIS 

I.  Artificial  Tongue. 

With  the  object  of  remedying  in  part  the  functional 
disabilities — dysphagia,  trouble  in  masticating  and 
speaking,  perpetual  flow  of  saliva  outside  the  mouth — 
resulting  from  an  amputation  of  the  tongue,  Martin 
has  at  different  times  inserted  an  appliance  to  replace 
this  organ.*     This  appliance  comprises  two  parts: 

*  Cl.   INIartin,    "  Treatise  of   Immediate  Prosthesis,"    18S9 
(Masson,  editor),  p.  374. 


LINGUAL  PROSTHESIS 


12 


1.  A  fixation  appliance,  made  of  a  lower  vulcanite 
plate  supported  by  the  remaining  teeth,  and  carrying 
artificial  teeth  to  replace  those  missing.  From  the 
front  and  inner  side  of  this  plate  a  prolongation  juts 
out,  of  variable  length,  made  of  flexible  vulcanized 
rubber,  and  is  directed  from  before  backwards  towards 
the  false  tongue  which  it  serves  to  support. 

2.  An  artificial  tongue  having  the  form  and  shape 
of  the  tongue  removed.  This  tongue  consists  of  a 
very  soft   and  thin  rubber  bag,   partly  filled  with 


Fig.  8g. — CI,  Martin's  Artificial  Tongue. 

water  or  an  antiseptic  fluid.  It  is  joined  to  the 
prolongation  of  the  lower  plate  by  a  very  mobile 
joint. 

Under  the  influence  of  movements  conveyed  to  it 
by  the  muscles  of  the  floor  of  the  mouth,  and  above 
all  by  the  muscular  sling  formed  by  the  mylohyoids, 
this  tongue  possesses  great  mobility.  It  can  be 
placed  against  the  palate  or  the  dental  arches,  and 
projected  from  the  mouth. 

Pont*  has  had  occasion  to  apply  an  artificial 
tongue  made  according  to  the  same  general  prin- 

*  Pont,  "  Some  Remarks  on  Lingual  Prosthesis  "  {Odon- 
tologie.  30  Sept.,  1903,  p.  335). 


126 


INJURIES  OF  THE  FACE  AND  JAW 


ciples;  but  he  substitutes  for  the  tongue-shaped 
rubber  prolongation  (which  is  to  support  the  bag 
of  water)  a  single  or  double  hinge.  He  has  obtained 
the  best  results  by  his  prosthetic  intervention. 

In  a  lecture  on  the  surgical  treatment  of  cancer 
of  the  tongue,*  Poncet  testified  to  the  services 
rendered  by  CI.  Martin's  invention  to  one  of  his 
patients,  whose  tongue  had  been  removed,  as  follows : 
"  Thanks  to  this  apparatus,  our  patient  no  longer 
loses  his  saliva;  he  swallows  easily,  like  anyone  else; 


Fig.  90. — Font's  Artificial  Tongue. 

he  no  longer  sends  out  heralds  (to  use  a  slang  ex- 
pression) when  he  talks.  He  eats  more  easily,  and 
can  even  to  a  certain  extent  put  his  tongue  out. 
These  movements  are  explicable  if  you  take  note  of 
this  observation,  that  the  mylohyoid  sling  was  not 
interfered  with  at  the  time  of  the  operation,  and  that 
the  contraction  of  the  mylohyoid  throws  forward 
the  floor  of  the  mouth." 

At  first  speech  is  but  little  improved,  for  the  patient 
must  be  long  accustomed  and  educated  to  the  false 
tongue ;  by  this  he  gradually  acquires  a  most  obvious 
improvement. 

*  Poncet,  Province  Med.,  16  Juin,  1888, 


LINGUAL  PROSTHESIS  127 

II.  Sheath  for  the  Tongue. 

Certain  ulcerations  of  the  tongue  are  extremely 
rebellious  to  all  treatment;  this  is  due  to  the  very 
great  mobility  of  the  organ,  which  makes  it  impossible 
to  apply  dressings  which  will  keep  their  place.  To 
make  such  dressings  possible,  and  thus  help  recovery, 
CI.  Martin  has  invented  the  following  apparatus , 
constructed  in  two  parts  (Fig.  91) : 


Fig.  91. — Tongue  Cover. 

A,  Rubber  sheath  enveloping  the  tongue;  B,  piece  playing 
on  the  lingual  surface  of  the  lower  alveolus;  C,  rubber 
ring  joining  the  sheath  of  the  cover  to  the  dental  piece. 

1.  A  sort  of  soft  rubber  sheath,  ensheathing  the 
tongue  and  holding  the  dressings  against  it. 

2.  A  base  plate  for  the  lower  jaw  which  serves  to 
keep  the  sheath  in  its  place,  by  means  of  an  elastic 
fixed  at  one  end  to  the  back  of  the  base  plate,  and 
at  the  other  end  to  the  front  of  the  sheath.  The 
sheath  is  thus  drawn  backwards  and  held  by  a  gentle 
and  constant  pressure,  which  allows  the  tongue  all 
its  movements,  but  prevents  it  leaving  the  sheath. 

Thanks  to  this  arrangement,  a  rebellious  ulceration, 
which  lasted  for  some  months,  has  been  cured  in  a 
few  days. 


128  INJURIES  OF  THE  FACE  AND  JAW 

CHAPTER  VI 

NASAL  PROSTHESIS 

We  distinguish  from  methods  of  restoration  of  the 
nose — 

1.  Autoplastic  methods. 

2.  Prosthesis    combined    with    autoplasty    (see 

p.  234)- 

3.  Internal  prosthesis  by  injection  of  paraffin. 

4.  Simple  late  prosthesis. 

It  is  only  of  the  last-mentioned  that  we  shall  speak 
here.  The  application  of  artificial  noses  goes  back 
to  a  very  ancient  era.  Ambroise  Pare  employs  them 
still,  making  them  of  gold  or  silver.  Metals,  hippo- 
potamus ivory,  and  such  plastic  substances  as  rubber 
and  celluloid,  have  in  succession  been  used  to  give 
them  a  more  natural  appearance;  later  we  paint  them. 
The  making  of  an  artificial  nose  necessitates  the  mould- 
ing of  the  whole  face  of  the  patient,  and  modelling  on 
this  mould,  in  wax,  a  nose  which  harmonizes  as  well 
as  possible  with  the  rest  of  the  physiognomy. 

The  materials  of  choice  to  employ  for  this  manu- 
facture are  hard  rubber,  alone  or  combined  with  soft 
rubber  at  the  edges;  and  rubber  supported  by  a 
metal  armature.  Apparatus  thus  made  are  solid, 
and  paint  sticks  to  them  strongly.  Nevertheless, 
soft  rubber  must  be  of  some  thickness,  and  has 
therefore  a  greater  weight;  and  its  manipulation  is 
beyond  doubt  more  delicate  than  that  of  hard  rubber. 
From  the  aesthetic  standpoint,  porcelain  noses  give 


NASAL  PROSTHESIS  129 

the  best  results,  but  that  is  an  undertaking  in  porce- 
lain work  which  is  always  most  difficult  to  execute 
Added  to  this  there  is  the  drawback  of  the  weight 
of    this    material,    which    demands    rigid    means    of 
fixation.     The  methods  of  fixation  of  artificial  noses 


Figs.  92  AXD'93. 


-Replacement  of  a  Nose  destroyed  by  Lupus. 
(Schwartz.) 


constitute  one  of  the  most  interesting  and  difficult 
of  nasal  prosthesis.  Following  CI.  Martin,*  we  will 
divide  them  into  four  principal  groups: 

I.  External  Procedures,  such  as  springs  encircling 
the  head,  coloured  head-pieces;  such  should  only  be 

*  Cl.  Martin,  "  Dental  Prosthesis  for  the  Bony  and  Soft 
Parts  of  the  Mouth  and  Face  "  (Rapport  au  Congr.  int.  de 
medecine,  Madrid,  Avril,  191 3). 


I30  INJURIES  OF  THE  FACE  AND  JAW 

employed  in  cases,  which  are  very  rare,  where  any 
other  method  is  impracticable.  Spectacles  provide 
an  ingenious  deception;  they  have  the  advantage 
that  they  can  carry  a  fairly  big  weight,  and  they  can 
be  used  with  advantage  on  patients  whose  sight 
requires  their  habitual  use. 

2.  The  Use  of  the  Nasal  Fossae. — We  take  advantage 
in  these  cases  of  rods  or  springs  taking  their  support 
from  the  outer  walls  of  the  upper  or  lower  nasal 
fossae.     [There  is  no  such  anatomical  division  of  the 


Fig.  94. — Replacement  of  a  Nose  destroyed  by  Lupus. 
(Schwartz.) 


fossae  in  our  nomenclature. — Tr.]  The  fact  that  the 
nose  should  weigh  very  little  and  the  pressure  of  the 
springs  be  very  weak  will  suggest  indications  for  the 
use  of  this  procedure.  It  seems  that  here  we  have 
the  means  of  retention  most  commonly  employed  by 
actual  prosthesists. 

CI.  Martin  has  used  it  often  for  many  years,  and  has 
never  observed  inflammatory  sequelae  of  the  nasal 
mucosa.  Schwartz  has  used  it  to  retain  a  nose  of 
hard  rubber,  a^^spring  gripping  the  septum,  and  some 


NASAL  PROSTHESIS 


131 


rounded  claws  taking  their  point  d'appid  from  the 
lower  border  of  the  nasal  fossa.* 

Royf,  in  a  case  of  partial  restoration  of  the  nose, 
has  used  an  original  method  of  retention.  The  loss 
of  substance  involved  all  the  left  wing  of  the  nose; 
the  wing  was  reconstituted  by  a  stamped  metal  plate, 
kept  in  place  by  two  grooved  rods,  each  one  ending 
in  a  soft  rubber  olive.  The  grooved  rods  are  soldered 
to  the  inner  face  of  the  metal  plate.     A  rubber  ring, 


Fig.  95. — Replacement  of  a  Nose  destroyed  by  Lupu; 
(Schwartz.) 


joining  the  rods  by  one  of  their  extremities,  tends  to 
make  them  slide  in  their  groove;  so  that  their  other 
ends,  covered  with  soft  rubber,  come  into  firm  con- 
tact with  the  margins  of  the  dehiscence,  thus  accom- 
plishing the  retention  of  the  appliance.     Delair,  who 

*  Schwartz,  "  Replacement  of  a  Nose  destroyed  by  Lupus  " 
(Cong.  dent,  de  Bordeaux,  1907,  in  Tahlettes  odontologiques , 
Dec,  1907,  p.  708). 

t  Roy,  "  A  Ca^e  of  Nasal  Prosthesis  "  {Odontologie,  15 
Janv.,  1906,  p.  5). 


132  INJURIES  OF  THE  FACE  AND  JAW 

recommends  the  use  of  soft  rubber  stiffened  by  a  bar 
of  aluminium,  uses  as  a  retention  appliance  springs 
which  take  their  support  from  the  nasal  fossae.* 
3.  Utilization  of  the  Teeth  of  the  Upper  Jaw.— 

This  plan  is  indicated  when  the  upper  lip  has  dis- 
appeared at  the  same  time  as  the  nose.  An  upper 
palatine  piece  is  fixed  to  the  teeth,  and  carries  a 
vertical  rod  passing  in   front   of  the   anterior  nasal 


Fig.  96. — Martin's  Apparatus. 

A  vertical  rod  supported  by  a  vestibular  band  traverses  the 
gingivo-labial  sulcus,  and  enters  the  nasal  fossae,  where 
it  acts  as  support  for  an  artificial  nose. 

Spine.  On  the  end  of  this  rod  are  mounted  the  nose 
and  the  false  lip  which  hides  the  appliance.  This 
procedure  has  been  apphedf  several  times  by  CI. 
Martin.  If  the  upper  lip  is  intact,  Martin  perforates 
the  gingivo-labial  cul-de-sac,   into  the  nasal  fossae, 

*  Delair,  "  Prosthesis  of  Palate,  Face,  and  Mouth  " 
(Rapport   au   XI Ve  Cong,   internat.  de   med.   leg.,    Madrid, 

Avril,  1903)- 

t  See  p.  144,  Fig.  98.  Mertens,  "  A  Case  of  Facial  Re- 
storation "  {Dental  Cosmos,  Mars,  1906,  and  Odontol.,  15  Mai, 
1907,  p.  416). 


NASAL  PROSTHESIS  133 

and  passes  through  this  hole  the  sustaining  rod, 
which  projects  for  i  or  2  centimetres  into  these 
fossae  at  the  side  of  the  anterior  nasal  spine  (Fig.  98). 
The  rod  is  itself  held  up  by  a  metal  band,  placed  in 
the  buccal  vestibule,  and  joined  behind  to  a  palatine 
plate  which  insures  its  immobility. 

Herein  we  have  a  neat  method  of  retention;  we 
need  not  in  a  suitable  case  hesitate  to  make  a  path 
for  the  sustaining  rod  of  the  nasal  apparatus,  by 
means  of  a  small  incision  in  the  vestibular  cul-de-sac. 
The  track  thus  made  epithelializes  without  delay, 
and  presents  no  inconvenience. 

4.  Employment  of  a  Palatine  Obturator. — This 
system  is  the  best,  and  gives  the  firmest  point  d'appui  ; 
but  it  is  only  applicable  when  through  a  palatine 
perforation  the  mouth  and  nose  communicate. 

According  to  Martin,  it  is  essential  that  this  fixa- 
tion should  not  be  rigid;  otherwise  it  immobilizes 
the  false  nose  in  a  given  position,  and  does  not  allow 
it  to  follow  the  face  movements  in  the  course  of 
mastication  or  the  various  play  of  the  physiognomy. 

Pont*  has  made  an  apparatus  consisting  of  three 
parts:  (i)  A  denture  supporting  the  nasal  rod;  (2)  a 
junction-piece;  (3)  a  painted  vulcanite  false  nose. 
The  denture  and  the  nose  exhibit  no  particular 
feature,  but  the  junction-piece  is  difficult  to  make 
and  adjust.  The  conception  of  the  mechanism  is 
CI.  Martin's,  but  Pont  has  modified  it  in  certain 
details.  The  principal  pieces  comprise — a  tube  with 
a  screw-thread,  an  intermediate  tube,  and  a  catch. 

*  Pont  and   Aveyron,    "Concerning  a   Case  of   Nasal   Pros- 
thesis" {Journal  ihs  mcdecins  praticicns,  Lyon,  Mai,  1910). 


134  INJURIES  OF  THE  FACE  AND  JAW 

The  junction-piece  allows  of  the  performance  of  the 
following  three  movements:  a  vertical,  a  horizontal, 
and  a  rotary. 

Below  we  give  the  schema  of  this  apparatus,  which 
gives  an  appreciation  of  its  ingenuity  and  value 
(see  Fig.  97). 

From  the  point  of  view  of  making  artificial  noses, 
we  are  compelled  to  limit  ourselves  to  some  general 
indications,  remembering  that  the  appliances  used 
are  most  diverse. 

I.  Porcelain  Work. — CI.  Martin  has  made  with 
porcelain  some  translucent  noses,  resembling  living 
skin,  which  far  outstrip  the  former  noses  of  painted 
ivory,  white  rubber,  or  enamelled  metal.  To  hold 
them  up,  these  noses  require  a  palatine  plate.  If 
there  is  a  perforation  of  the  vault,  we  profit  by  it 
to  pass  up  a  vertical  rod  which  reaches  the  nasal 
fossae;  if  no  perforation  exists,  we  create  one  {vide 
p.  132),  in  the  upper  gingivo-labial  groove. 

The  use  of  spectacles,  since  they  give  much  less 
steadiness,  should  be  abandoned.  The  false  nose 
carries  at  its  posterior  part  a  horizontal  rod  attached 
to  a  spherical  joint,  which  plays  on  the  vertical  rod 
(of  the  palatine  plate)  in  the  nasal  fossae.  By  means 
of  an  ingenious  arrangement — a  small  spiral  spring 
which  acts  on  the  horizontal  rod  and  keeps  the  false 
nose  always  snug  against  the  skin — the  appliance 
follows  the  movements  of  the  soft  tissues  to  which 
it  fits. 

With  the  aid  of  a  small  button  hidden  in  the  nostril 
we  unhitch  and  disarticulate  the  nasal  and  buccal 
sections  of  the  appliance. 


NASAL  PROSTHESIS 


135 


Q 


J? 

F=EF 


I  ube-  ccfOK. 


K|      -p 


IIZ7 


J^ 


0: 


T H.[)C     toccot^ 


^■,n!}»<ir':tni!n'nitnnn/ 


:^v..  .V.l^  »'<-tsm:.^sv.~v<^^Vx<vv^-^vv^.^|^:ivv^t..  ■  Ail 


CoiA*«  (it  lA.  Lji'Mt  de. 


UL6t»V«.4iM.frV>-C 


Fig.  97. — Artificial  Nose  and  its  Mechanism,  by  Pont,  of  Lyons 


Detail. 

Piece  de  raccordement  =  Junction-piece. 
Tube-6crou  =  Tube  with  screw-thread. 
Tube  raccord  =  Intermediate  tube. 
Detente  =  Catch. 

Ne2=Nose.  ^ 

Tige  na.sale  =  Nasal  rod. 
Appareil  dentaire  =  Denture. 
Appareil  compIet  =  Apparatus  assembled. 
Eiastique  =  Elastic. 

Coupe  de  la  piece  de  raccordement  =  Sec- 
tion of  the  junction-piece. 


Key. 

A.  Screw  of  the  tube  which  slides  on  the 

nasal  rod. 

B.  Trigger. 

C.  Internal  pin  of  the  catch. 

D.  Horizontal  limb  of  the  catch. 

E.  Shoulder  of  tube  with  screw-thread. 

F.  Tuba  with  screw-thread. 

G.  Nut  fused  into  artificial  nose. 
H.  Elastic  to  hold  the  catch. 

I.    Intermediate  tube  sliding  in  the  tube 

with  screw-thread. 
K.  External  pin  of  the  catch. 


136  INJURIES  OF  THE  FACE  AND  JAW 

Construction  of  the  Nose  in  Porcelain. — Having 
taken  a  mould  of  the  face,  we  stamp  out  a  nose  in 
very  thin  platinum  {-^  mm.),  which  is  to  support 
the  porcelain  paste.  So  as  to  prevent  it  losing  its 
shape  during  the  fusing,  we  reinforce  this  provisional 
nose  by  pouring  into  the  interior  a  mixture  of  plaster 
and  diamond  dust.  We  place  the  screws  which  will 
fix  the  horizontal  branch,  and  we  apply  the  porcelain 
material,  which  consists  of  kaolin,  feldspath,  etc.; 
it  is  coloured  by  Allen's  paste,  purple  of  Cassius, 
spongy  platinum,  and  above  all  precipitated  gold, 
which  gives  translucency  and  live  appearance  to  the 
false  nose.  We  fuse  several  times,  repair  the  cracks, 
and  gradually  arrive  at  a  thickness  of  2  mm.  We 
cool  slowly,  remove  the  plaster,  and  with  the  utmost 
care  the  platinum-leaf;  the  screws  remain  fixed  in 
the  porcelain.  W^e  rub  off  the  bright  porcelain,  and 
obtain  a  velvety  surface  resembling  that  of  the  skin 
by  exposing  the  piece  to  the  fumes  of  hydrofluoric 
acid.  It  only  remains  to  adapt  the  horizontal  branch, 
and  we  have  the  nasal  part  of  the  apparatus.  One 
important  detail:  it  is  necessary,  so  that  the  line  of 
junction  with  the  soft  tissues  may  be  as  little  visible 
as  possible,  for  the  margins  of  the  artificial  nose,  much 
thinned  out,  to  lie  on  the  skin,  as  it  were,  quite  fiat, 
without  a  suggestion  of  any  thickness.  If  there  is 
a  loss  of  substance  of  the  upper  lip,  we  join  on  to 
the  nose  an  artificial  lip  to  replace  the  missing  part. 

Martin  has  obtained  with  his  porcelain  noses 
marvellous  results,  such  good  imitations  that  they 
are  mistaken  for  the  real  organs. 

2.  Hard  Rubber  is  used  much  oftener  than  porce- 


NASAL  PROSTHESIS  137 

lain  by  reason  of  its  lightness,  and  above  all  because, 
of  all  materials  employed  in  prosthesis,  it  is  the 
easiest  to  work  and  the  most  familiar  to  dentists. 
Therefore  we  will  not  expatiate  upon  its  manipula- 
tion. Hard  or  soft  rubber  should  be  painted  when  it 
is  used  to  replace  part  of  the  integuments.  So  that 
the  imitation  of  the  skin  should  be  better,  it  is  helpful 
to  paint  the  appliance  after  it  has  been  placed  on 
the  patient's  face,  or  at  any  rate  to  retouch  it  while 
in  situ.  In  this  way  we  get  a  more  exact  harmony 
between  the  tints  of  the  face  and  the  tones  of  the 
false  nose  fitted  to  it. 

For  making  a  nose  of  vulcanite,  Pont  has  remarked 
that  it  is  advantageous  to  model  the  piece  in  wax, 
for  many  reasons  which  he  enumerates: 

1.  Wax  does  not  retract  like  dry  clay. 

2.  One  can  make  the  modelling  in  several  stages, 
which  is  preferable,  as  the  faults  leap  to  one's  eye. 

3.  Glazing  the  wax  with  a  flame  aids  us  by  giving 
to  the  lines  a  softness  difficult  of  achievement  with 
a  sketching  chisel  and  the  finger. 

4.  The  junction-piece  may  be  adjusted  actually 
on  the  patient;  so  also  the  smoothing  of  the  edges. 

5.  Once  the  piece  is  finished,  one  can  pour  a  mould; 
thus  one  will  have  pieces  the  exact  counterpart  of 
each  other  and  easily  interchangeable.  To  facilitate 
the  modelling,  Pont  gives  some  measurements  which 
enable  us  to  reconstitute  the  nose  almost  exactly. 

[a)  Length  of  nose  from  root  to  tip  =  width  of* 
closed  mouth. 

(b)  Internal  breadth  from  one  nostril  to  the  other 
=  breadth  of  a  closed  eyelid. 


138  INJURIES  OF  THE  FACE  AND  JAW 

(c)  Distance     from     columella     to     lip  =  vertical 
diameter  of  interpalpebral  opening  with  eyes  open. 

{d)  Width  of  one  nostril  =  depth  of  the  upper  lip. 

If  we  drop  two  parallel  lines  from  the  inner  canthus 
perpendicular  to  the  lips,  we  define  the  external 
breadth  of  the  nostrils. 

Painting  on  Vulcanite. — We  can  make  use  of  the 
following  colours  in  oil:  Silver  white,  lake  carmine, 
Naples  yellow.  It  is  difficult  to  suggest  the  quantities 
requisite,  for  the  mixture  is  subordinated  to  the  tint 
wanted.  To  make  the  colour  dry  rapidly,  it  will  be 
well  to  soak  the  brush  in  essence  of  petrol  and  dilute 
the  colour.  In  a  few  hours  drying  is  complete.  To 
make  the  colouring  uniform,  we  dip  the  finger  in 
pumice  and  glycerine  and  pass  it  over  the  dry  paint- 
ing. We  rub  gently,  and  finish  the  operation  by 
washing  in  running  water. 

3.  Soft  Rubber  has  to  be  used  of  a  greater  thick- 
ness than  hard;  it  has  accordingly  the  drawback  of 
giving  heavier  apparatus.  Its  manipulation  is  more 
difficult  than  that  of  hard  rubber.  None  the  less, 
Delair  shows  himself  to  be  a  converted  partisan  to 
soft  rubber.  He  reduces  its  weight  by  using  an 
armature  of  aluminium ;  and,  thanks  to  this  ingenious 
combination,  he  has  obtained  excellent  results  by 
thus  ridding  himself  of  one  of  the  gravest  disad- 
vantages of  soft  rubber  from  the  point  of  view  of 
its  use  for  nasal  prosthesis.* 

To  make  these  appliances  in  soft  rubber,  Delair 
always  employs  moulds  made  of  the  same  metal  as 
printer's  type.     He  prefers  metal  to  plaster,  on  the 
*  Delair,  Rapport  au  Cong,  de  Madrid,  1903. 


NASAL  PROSTHESIS  139 

ground  that  the  mould,  once  obtained,  can  serve 
indefinitely  for  the  subject  for  whom  the  prosthesis  is 
destined,  at  any  time  when  it  is  necessary  to  make 
for  him  a  new  appliance. 

To  vulcanize  the  soft  rubber,  we  steep  the  moulds 
for  some  hours  in  a  vat  of  melted  sulphur,  kept  at 
a  uniform  temperature  on  a  sand-bath.  It  is  more 
simple  to  use  the  rubber  employed  in  dentistry  by 
proceeding  according  to  the  following  scheme  out- 
lined by  Delair:  The  flask  or  mould,  being  stuffed 
with  white  or  pink  rubber,  is  placed  in  the  vulcanizer, 
taking  care  to  let  this  stand  on  a  pedestal  of  porce- 
lain; an  inverted  saucer  will  do.  The  vulcanizer  is 
now  heated  slowly,  until  the  thermometer  says  155°  C. 
(which  corresponds  to  a  pressure  of  5' 5  atmospheres). 
At  this  moment  we  suddenly  allow  the  steam  to 
escape,  open  the  boiler,  and  rapidly  plunge  the  mould 
into  cold  water  until  it  is  cool. 

Rubber  thus  treated  by  this  partial  vulcanizing 
remains  soft,  all  the  while  keeping  the  shape  given 
to  it;  the  surface  of  the  piece  is  smooth  and  ready 
to  be  painted.  It  is  understood  that  the  metal 
armature  sustaining  the  appliance  is  enclosed  in  it 
at  the  moment  of  filling.* 

"  There  is  one  disadvantage  common  to  all  arti- 
ficial noses,  the  flow  of  all  nasal  secretions  and  of 
water  (condensed  from  the  water-vapour  of  expired 
air)  into  the  hollow  on  their  posterior  surface.  These 
fluids  now  and  then  trickle  down  along  the  tissues 
beneath  the  appliance.  We  rectify  this  incon- 
venience by  filling  the  concavity  of  the  false  nose  by 
*  Delair,  Rapport  Congr.  de  Madrid,  p.  20. 


I40  INJURIES  OF  THE  FACE  AND  JAW 

a  bag  of  soft  or  only  partially  vulcanized  rubber. 
This  bag  will  be  moulded  on  the  whole  concavity,  and 
also  on  all  the  anterior  and  inferior  part  of  the  open- 
ing, only  leaving  two  oblique  passages.  These  are, 
respectively,  above,  which  conveys  air  to  the  upper 
regions  of  the  nose;  and  behind,  which  leads  to  a 
level  slightly  higher  than  the  nasal  floor.  Thanks 
to  this  arrangement,  the  products  of  secretion  are 
obliged,  in  order  to  flow  out,  to  follow  the  posterior 
pharyngeal  route.  And  the  hollow  of  the  nose, 
being  filled  up,  cannot  act  as  a  reservoir  for  condensa- 
tion of  aqueous  vapour."* 

Henning's  New  Process. — Henning's  method  seems 
destined  to  revolutionize  prosthetic  restoration. 
Warnekros  has  exhibited  a  patient,  treated  by  this 
method,  at  the  Odontological  Society  at  the  May, 
1913,  session;  and  since  that  time  Pont  of  Lyons  has 
been  the  first  to  use  it  in  France. 

Appliances  constructed  with  the  help  of  the  new 
process  are  frankly  superior  from  all  points  of  view 
to  those  made  up  to  date  with  the  divers  materials 
which  we  have  reviewed  in  passing. 

The  qualities  of  this  new  substance  appear  to 
answer  in  a  perfect  way  to  all  practical  demands. 
Its  chief  advantages  are  as  follows: 

{a)  Simplicity  and  rapidity  of  the  process. 

(6)  iT^sthetic  results  approximating  to  perfection, 
as  much  from  the  standpoint  of  appearance  as  from 
that  of  shape  and  consistency.  Noses  made  by  this 
process   have   almost   completely  the   characters    of 

*   Cl.  Martin,  Congr.  de  ]\Iadrid,  p.  22. 


NASAL  PROSTHESIS  141 

human  tissue,  and  may  be  dented  without  deforming 
them;  even  to  touch  them  gives  a  sensation  of  real 
tissue. 

(c)  Their  fit  and  adhesion  are  beyond  reproach; 
and  these  artificial  noses,  be  their  shape,  volume, 
and  extent  what  it  may,  remain  in  place  without 
any  call  for  retention  appliances.  These  latter  were 
generally,  with  the  old  methods,  difficult  to  put 
together  and  make,  and  were  often  badly  tolerated 
by  the  patient. 

To  sum  up  the  way  they  are  made:  An  impression 
is  taken,  and  we  proceed  as  if  wishing  to  construct 
a  nose  of  wax.  We  then  make  a  mould  suiting  as 
far  as  possible  the  general  cast  of  countenance,  and 
pour  into  this  mould  Henning's  paste.  This  latter 
is  a  plastic  gelatinous  material,  which  the  patient 
himself  can  repeatedly  recast  and  use  afresh.  To 
do  this  it  suffices  to  give  him  his  mould  and  Henning's 
,  paste.  Another  point  of  originality  of  this  plan  is 
in  the  mode  of  fixing.  Once  modelled,  the  false 
nose  is  merely  closely  applied  to  the  skin  with  the 
help  of  a  special  material. 


CHAPTER  VII 
AURICULAR  PROSTHESIS 

As  regards  the  material  of  choice,  preference  should 
be  given  to  rubber;  for  celluloid  changes,  and  Vv^ax  is 
too  heavy.  As  in  most  surgical  prostheses,  the 
interest  of  these  lies  in  the  mode  of  retention. 


142  INJURIES  OF  THE  FACE  AND  JAW 

Two  conditions  may  present  themselves: 

1.  The  auricle  has  disappeared. 

2.  Part  of  the  ear  remains. 

In  the  first  case,  the  steel  rod  which  holds  the 
appliance  passes  vertically  up  on  to  the  head.  At 
its  lower  end  it  carries  a  projection  which  enters  the 
external  meatus.  In  the  second  case,  the  rudi- 
mentary [or  vestigial — Tr.]  stump  is  of  great  assist- 
ance. It  can  be  perforated  in  such  wise  as  to  give 
a  passage  for  a  spring,  or  surrounded  by  the  artificial 
ear ;  or  simply  enclosed  in  the  concavity  of  the  appli- 
ance. Henning's  method  will  probably  find  a  happy 
application  in  numerous  cases  of  auricular  prosthesis. 


CHAPTER  VIII 

PROSTHESIS  OF  LIPS 

The  same  remark  applies  to  these  organs  as  to  pros- 
thesis of  the  tongue.  From  the  point  of  view  of 
their  restoration,  their  mobility  constitutes  an  ob- 
stacle which  we  must  conquer  if  we  wish  to  give  the 
suppleness  and  mobility  which  are  indispensable  to 
facial  expression.  It  is  but  rarely  that  we  have  to 
replace  these  organs  alone;  in  the  vast  majority  of 
cases  their  restoration  goes  with  that  of  the  nose, 
maxillse,  hard  palate,  or  cheek.  The  materials  used 
are  porcelain  and  soft  solid  rubber.  The  mobility 
of  porcelain  being  nil,  and  that  of  solid  rubber  in- 
sufficient, Martin  has  theoretically  advocated  that, 
in  making  the  lip,  the  soft  rubber  should  be  hollow 


EXTENSIVE  BUCCO-FACIAL  RESTORATIONS    143 

and  filled  (without  tension)  with  water.  We  say 
theoretically,  because  this  authority  has  not  applied 
his  process.  The  base  of  the  lip,  of  hard  rubber, 
presents  at  its  least  visible  part  a  small  orifice  by 
which  one  fills  the  cavity  with  water,  without,  how- 
ever, filling  it  completely,  leaving  a  small  space 
empty.  This  arrangement  would  have  the  advantage 
of  allowing  the  organ  to  change  its  shape  under  the 
influence  of  pressure  at  any  point,  thus  giving  it  a 
more  natural  aspect.  Moreover,  occlusion  of  the 
lips  would  be  more  perfect,  and  pronunciation  would 
be  to  a  large  extent  the  gainer.  Henning's  new 
method  would  seem  indicated  for  this  prosthesis. 


CHAPTER  IX 

EXTENSIVE    BUCCO-FACIAL    RESTORATIONS 

The  extreme  diversity  of  cases  of  this  order,  the 
arge  number  of  appliances  invented  to  remedy  them, 
will  hardly  allow  of  establishing  any  method  for  the 
treatment  of  this  sort  of  case.  There  is,  however,  a 
certain  number  of  principles  from  which  one  cannot 
deviate,  if  good  results  are  to  be  got.  The  first  may 
be  thus  defined:  On  all  occasions  when  the  facial 
cavities  have  been  involved  and  laid  open,  and  show 
a  loss  of  substance,  one  should  strive  to  fill  them  as 
completely  as  possible,  leaving  no  chasm  other  than 
the  normal  anatomical  space  necessary  for  the  fulfil- 
ment of  physiological  functions.  As  a  corollary  to 
this,  it  is  necessary  to  make  bulky  apparatus. 


144  INJURIES  OF  THE  FACE  AND  JAW 

Accordingly,  these  latter  should  be  light.  To 
answer  to  this  desideratum  of  lightness,  it  is  useful 
to  construct,  as  far  as  possible,  hollow  appliances; 
a  combination  of  aluminium  and  rubber  forms  the 
material  of  choice  in  such  cases.  It  is  difficult  to 
describe  these  facial  restorations;  each  case  occurs 
under  individual  conditions.  We  may  quote  the 
primitive  appliances  of  Delalain,  then  those  of 
Lecaudey,     Dejardin,     Preterre,     and     Goldenstein; 


Fig.  98.— Facial  Restoration:  ^lertens'  Case. 


finally  the  more  modern  contrivances  devised  by 
Gunning,  Kingsley,  Haupmann,  Michaels,  Ronnet, 
Martin,  and  Delair. 

Apropos  of  these  extensive  appliances  for  restora- 
tion, the  most  interesting  point  to  study  is  the  plan 
for  their  retention;  this  may  vary  with  the  peculiari- 
ties of  each  case  which  is  presented  to  the  prosthesist. 
As  a  rule  the  point  d'appui  is  taken  from  the  maxilla, 
or  its  remains,  through  the  intervention  of  a  large 
palatine  appliance.  When  the  nasal  scaffolding  is 
destroyed  as  well  as  the  upper  lip,  the  mechanism 
for  attaching  the  prosthetic  mask  to  the  palatine 


EXTENSIVE  BUCCO-FACIAL  RESTORATIONS    145 

plate  passes  easily  through  the  gap  in  the  nose. 
Take  the  very  elementary  example  of  Mertens* 
(Fig.  98).  It  concerned  a  patient  for  whom  the 
nose,  upper  lip,  and  incisive  region,  had  to  be  re- 
placed. The  following  is  the  conception  of  the 
appliance : 

1.  Palatine  plate  restoring  the  incisive  region  and 
serving  as  a  support. 

2.  Vertical  metal  rod  inserted  into  the  buccal  part 
and  traversing  the  nasal  gap.  On  this  rod  a  spiral 
spring  like  those  of  dentures,  the  end  of  the  spring 
being  left  free. 

3.  A  mask  of  painted  rubber  reconstituting  the 
nose  and  upper  lip,  and  carrying  a  false  moustache. 

The  mask  is  hooked  on  by  a  ring  to  the  free  end 
of  the  spring  supported  by  the  palatine  piece.  The 
backward  pull  of  this  spring  keeps  the  appUance 
exactly  fitted  on  to  the  face. 

But  as  a  rule  the  tattered  condition  of  the  face  is 
such  that  we  must  have  recourse  to  much  more 
complicated  processes.  Delairf  has  published  many 
such  which  we  cannot  here  describe  in  detail.  Among 
the  most  ingenious  we  may  mention — 

I.  Retention  by  hooking  on  with  a  catch.  Two 
levers  with  catches  facing  each  other  close  the  open- 
ings of  two  pieces  of  tubing;   into  these  latter  are 

*  Mertens,  "  A  Case  of  Facial  Restoration  "  {Dental 
Cosmos,  Mars,  1906,  and  Odontologie,  15  Mai,  1Q07,  p.  146). 

t  Delair,  "  A  Case  of  Bucco-Facial  Prosthesis:  New 
Mechanism  of  Fixation  "  [Journ.  odontologiqice  de  France, 
Oct.,  1909,  p.  247).  See  also  Delair,  "  Report  on  Bucco- 
Facial  Prosthesis"  (Cong,  de  Madrid,  1903)- 


146 


INJURIES  OF  THE  FACE  AND  JAW 


introduced  two  parallel  rods  of  gold,  fixed  to  the  back 
of  the  mask  and  holding  it. 

2.  Retention  by  elastic  traction  in  an  antero- 
posterior plane.  On  the  incisive  region  of  a  palatine 
apparatus  a  metal  lever  is  fixed  by  a  hinge;  the  end 
of  this  lever  supports  a  facial  mask.  By  its  middle 
part  it  is  joined  to  the  palatine  appliance  by  a  rubber 


^/ 


f 


Fig.  99. — Appliance  for  Bucco-Facial  Prosthesis. 
(Delair's  case). 


loop.  The  elastic  traction  tends  to  raise  this  lever 
and  move  it  backwards,  and  so  it  presses  all  the  more 
snugly  against  the  surface  of  the  painted  rubber 
mask  which  it  supports.  People  have  often  sought 
to  use  the  ears  as  a  point  d'appui  to  insure  the  re- 
tention of  large  bucco-facial  restoration  appliances. 


EXTENSIVE  BUCCO-FACIAL  RESTORATIONS    147 

In  such  cases  they  avail  themselves  of  spectacles, 
which  look  as  if  they  were  doing  their  real  work. 
But  the  pressure,  sometimes  fairly  strong,  which  is 
thus  exercised  on  the  retro-auricular  groove,  occa- 
sionally becomes  painful,  and  patients  complain  of 
this  frequently. 

Lastly,  there  are  other  cases  where  the  absence  of 
communication  between  the  mouth  and  the  part  of 
the  face  to  be  restored  makes  the  problem  of  reten- 
tion very  difficult  to  solve.  One  of  us*  found  this 
in  the  following  case,  operated  on  by  M.  Sebileau  for 
an  epithelioma  of  the  cheek.  The  patient  recovered, 
with  a  large  gap  in  the  malar  region.  The  malar 
bone  had  been  resected,  and  the  antrum  was  open 
externally.  The  surgical  procedure  had  made  no 
communication  between  mouth  and  antrum,  such 
as  could  be  used  to  pass  a  retention  appliance  for 
,  holding  to  the  skin  a  mask  to  fill  the  large  gap.  The 
invalid,  very  senile,  was  entirely  edentulous,  and 
with  our  colleague  Geoffroy  we  adopted  the  foUowing 
plan: 

1.  A  support  derived  from  a  complete  upper 
denture. 

2.  A  mask  of  stamped  and  painted  aluminium., 
covering  the  facial  gap  and  reconstituting  the  con- 
tours of  the  malar  region. 

3.  A  V-shaped  spring  turning  round  the  labial 
commissure;  one  of  its  ends  is  supported  by  the 
denture  by  fitting  into  a  socket  made  for  the  purpose. 

*  Leraerle  and  Geofiroy,  "  Late  Prosthetic  Restoration  of 
the  Cheek  and  Malar  Region  "  {Odontologie,   30  Aout,  190S 
P-  i4o)- 


148  INJURIES  OF  THE  FACE  AND  JAW 

The  other  end,  fixed  to  the  inside  of  the  cheek  mask, 
draws  it  firmly  backwards,  thus  keeping  it  close- 
fitting  to  the  soft  parts  around. 

It  is,  then,  evident  that,  in  the  matter  of  bucco- 
jacial  restoration,  the  most  important  part  lies  in 
the  making  of  a  good  means  of  retention  for  the 
prosthesis.  Each  sufferer  who  consults  the  pros- 
thesist  offers  him  a  new  problem  to  solve,  and  nearly 
always  this  problem  turns  on  the  means  of  retention 
to  be  adopted,  which  varies  with  each  case.  Where- 
fore it  is  impossible  to  lay  down  any  law  on  the 
subject;  that  is  why  we  hmit  ourselves  to  citing  a 
jew  general  examples. 


SECTION    II 
IMMEDIATE   PROSTHESIS 

Systems  of  immediate  prosthesis  fall  into  two 
groups,  having  this  common  characteristic:  that  we 
place  in  the  tissues  apparatus  intended  to  be  tem- 
porary, and  do  not  reckon  on  them  being  permanently 
tolerated  by  the  tissues.  The  two  groups  are — 
Immediate  prosthesis  for  subperiosteal  resection;  and 
immediate  prosthesis,  properly  so  called,  when  it  is 
intended  to  oppose  cicatricial  retraction. 


CHAPTER  I 

PROVISIONAL    PROSTHESIS    APPLIED    IN    THE 
CASE  OF  SUBPERIOSTEAL  RESECTIONS 

This  is  destined  to  act  as  a  guide  to  the  periosteal 
flaps  and  to  the  newly  formed  bone  tissue,  so  as  to 
aim  at  regeneration  of  the  portion  of  skeleton  re- 
sected. On  account  of  its  difficulties,  this  method 
has  been  but  little  used.  Nevertheless,  CI.  Martin 
since  1878  has  obtained  good  results  in  two  remark- 
able instances.  He  was  concerned  with  two  cases  of 
massive  necrosis  of  the  lower  jaw.     The  sequestra 

149 


I50  INJURIES  OF  THE  FACE  AND  JAW 

had  been  removed  and  the  periosteal  gutter  spared. 
Martin,  placing  his  appliance  in  this  gutter,  reduced 
the  former  little  by  little,  until  the  new  bone  was 
sufficiently  resistant  for  the  artificial  support  to  be 
removed  from  the  soft  parts  without  risk  of  deformity. 
Thus,  his  appliance  answered  by  instantly  checking 
the  functional  disabilities  consecutive  to  necrosis  and 
the  formation  of  undoubtedly  vicious  new  bone,  dis- 
abilities which  would  occur  in  the  train  of  the  collapse 
of  soft  parts  and  cicatricial  retraction. 

Applied  later  by  Pean  and  Michaels,  these  Authors 
have  published  some  interesting  observations  where 
this  class  of  prosthesis  seems  to  have  yielded  remark- 
able results,*  especially  having  regard  to  the  extent 
of  the  resection  and  the  region  in  which  it  took  place. 
The  resection  concerned  was  of  the  upper  two-thirds 
of  the  humerus. 

We  must  bear  in  mind  that,  in  their  method,  the 
prosthetic  appliance  is  put  in  provisionally.  When 
bony  regeneration  has  been  obtained,  the  appliance, 
in  the  course  of  a  second  intervention,  is  removed. 
In  this  way  we  shall  at  least  understand  the  raison 
d'etre  of  this  procedure:  that  the  periosteum,  spared 
during  the  surgical  attack,  has  been  fixed  by  the 
operator  to  the  prosthetic  appliance  with  the  idea 
of  obtaining  bony  regeneration. 

*  Michaels,  "  Demonstration  of  Appliances  intended  to 
repair  Losses  of  Skeletal  Substance  "  (Cong.  dent,  nat.; 
Nancy,  1896,  p.  22). 


PROVISIONAL  PROSTHESIS  151 

CHAPTER  II 

IMMEDIATE  PROVISIONAL  PROSTHESIS 

DESTINED  TO  OPPOSE  CICATRICIAL 

RETRACTION 

According  to  this  plan,  we  preserve,  in  the  deptn 
of  a  wound  undergoing  epithehahzation,  a  space 
which  shall  later  be  filled  by  a  removable  appliance 
intended  to  replace  the  resected  portion  of  the 
skeleton. 

This  method  was  used  for  the  first  time,  and  with 
success,  by  CI.  Martin,*  April  13,  1878,  on  a  patient 
whose   horizontal   mandibular   ramus   had   been   re- 
sected by   Letievant.     Certain  surgeons,   struck  by 
the  inconveniences  resulting  from  resections  of  any 
part  of  the  lower  jaw,  tried  to  -remedy  them  either, 
like   Rigal  of   Gaillac,   by  placing   in  the  wound  a 
piece  of  lead,  or,  like  Stanley,  a  plate  of  ivory,  or, 
like    others,    a    piece    of    gutta-percha.     But    these 
divers  efforts  gave  only  mediocre  results.     Verneuil, 
in  1874,  fixed  between  the  fragments  a  metal  loop 
to  support  the  tongue  and  prevent  it  from  falling 
dovv^n  after  a  resection  of  the  region  of  the  symphysis. 
This  was  the  only  object,  and  this  procedure  gave 
no  relief  to  the  other  functional  troubles  nor  to  the 
facial  deformity.     So  we  can  really  say  with  perfect 
justice  that  CI.  Martin  thought  out  the  principle  of 
immediate  prosthesis,  and  was  the  first  to  regularize 
the   technique.     Therefore   it   is   his   which   we   are 

*  CI.  Martin,  "On  Immediate  Prosthesis  applii  I  to  Re- 
section of  the  Upper  Jaws,"  Paris,  1889. 


152  INJURIES  OF  THE  FACE  AND  JAW 

proposing  to  study,  especially  because  of  its  fairly 
frequent  practical  application. 

Immediate  prosthesis*  consists  essentially  of  two 
stages : 

1.  Immediate  replacement  of  the  bony  segment 
resected,  by  an  appliance  fixed  in  the  depth  of  the 
tissues  before  suturing  the  soft  parts. 

2.  When  cicatrization  is  complete,  the  temporary 
appliance  is  removed  and  replaced  by  a  final  movable 
appliance. 

The  aim,  then,  of  immediate  prosthesis  is  to  oppose 
a  preventing  or  prophylactic  action  to  the  cicatricial 
contraction  which  follows  a  bony  resection.  Such 
retraction  can  lead  to  serious  sequelae  at  the  level 
of  the  lower  jaw.  It  is,  maybe,  for  this  reason  that 
immediate  prosthesis  constitutes  a  method  which  is 
used  ahTiost  exclusively  for  such  resections  of  the 
lower  jaw,  which  can  be  followed  by  various  accidents 
which  we  will  rapidly  enumerate. 

CHAPTER  III 

ACCIDENTS  FOLLOWING  RESECTIONS  OF  THE 
LOWER  JAW  NOT  FOLLOWED  BY  PROSTHESIS 

Such  accidents  may  be  divided  into — 

1.  Primary  accidents,  supervening  during  the 

first  fifteen  days  after  operation. 

2.  Secondary  accidents. 

I.  Primary  Accidents. — In  the  days  following  the 
resection,  the  invalid  complains  of  not  being  able  to 

*  IMartin,     "  Oa     Immediate     Prosthesis,"     Paris, 
Masson,  editor. 


PRIMARY  AND  SECONDARY  ACCIDENTS     153 

masticate,  because  the  teeth  are  no  longer  in  contact 
the  remaining  segment  of  the  lower  jaw  being  drawn 
inwards  and  backwards.  Soon  this  deviation,  caused 
at  the  beginning  by  the  upset  of  muscular  balance 
only,  becomes  more  and  more  accentuated  under  the 
influence  of  the  cicatricial  retraction.*  The  infra- 
hyoid mass  of  soft  parts,  ceasing  to  be  kept  up  by 
the  mandibular  horseshoe,  sinks  down  and  slides 
downwards  and  backwards.  Out  of  this  arises  a  lot 
of  dysphagia  and  dysphonia.  When  the  resection 
has  involved  the  front  part  of  the  jaw  and  destroyed 
the  bony  origin  of  the  genio-glossi,  the  tongue,  not 
being  kept  forward  by  these  muscles,  is  dragged  back- 
wards and  closes  the  laryngeal  passage  by  inhibiting 
the  raising  of  the  epiglottis — hence  asphyxia. 

2.  Secondary  Accidents. — Under  the  influence  of 
cicatricial  retraction,  the  bony  fragments  approach 
one  another.  The  facial  deformity  is  considerable, 
and  the  situation  of  the  unfortunate  subject  pitiable. 
Dysphonia  is  aggravated,  words  being  replaced  by 
unintelligible  grunts.  The  dental  arches  no  longer 
correspond,  and  any  solid  feeding  is  impossible. 
Swallowing  is  difficult,  and  fluids  (the  only  nourish- 
ments the  patient  can  take)  escape  from  the  mouth 
and  soil  the  face  and  clothes.  When  at  rest,  saliva 
flows  in  a  continuous  trickle  between  lips  powerless 
to  keep  it  back. 

These  accidents,  more  especially  the  secondary 
ones,    are    grave    and    intractable.     The    appliances 

*  Billing  has  published  an  interesting  study  on  the  causa- 
tion of  deviations  secondary  to  partial  resections  of  the  lower 
jaw.  (See  Billing,  on  "Prosthesis  for  Resections  of  the 
Mandible,"  Stockholm,  1910.) 


154  INJURIES  OF  THE  FACE  AND  JAW 

employed  in  late  prosthesis  for  reducing  cicatricial 
bands  cannot  prevent  the  primary  accidents.  Im- 
mediate prosthesis  has  their  prevention  for  its 
specific  object;  it  is  a  prophylactic  method.  The 
end  in  view  of  the  science  of  immediate  prosthesis 
is  to  replace  the  resected  bone  at  once  by  an  appli- 
ance (roughly  a  replica  of  the  part  removed).  As 
a  fact,  it  is  unnecessary  to  reproduce  exactly  the 
skeletal  details.  Above  all,  one  must  devote  oneself 
to  copying  the  general  form  of  the  bone,  all  the 
while  taking  care  (to  borrow  a  term  used  in  moulding) 
to  construct  a  prosthetic  piece  which  will  be  easy  to 
cast  off.  This  provisional  appliance  is  fixed  to  the 
remaining  portions  of  bone,  resists  retraction,  guides 
the  scar  tissue,  and  prevents  the  primary  accidents 
of  which  we  have  just  been  speaking. 

After  the  lapse  of  a  certain  time — Martin  says  as 
soon  as  possible — when  scarring  is  finished,  this 
provisional  appliance  is  replaced  by  a  more  finished 
article,  furnished  with  artificial  teeth.  This  is  the 
second  or  permanent  apparatus,  which  prevents  the 
secondary  accidents  already  enumerated. 


CHAPTER  IV 

CONDITIONS  TO  BE  FULFILLED  BY  AN  APPLI- 
ANCE OF  IMMEDIATE  PROSTHESIS 

The  apparatus  which  is  to  replace  any  part  whatever 
of  the  mandible  should  always  be  larger  than  the 
part  to  be  resected.     It  is  preferable  always  to  make 


APPLIANCES  FOR  IMMEDIATE  PROSTHESIS    15 


00 


a  compld;e  jaw,  from  which  we  cut  off  portions 
corresponding  to  the  bony  parts  which  the  surgeon 
has  spared.  For  the  jaw  may  be  affected  by  more 
extensive  resections  than  at  first  anticipated;  and 
if  we  make  an  apphance  on  the  original  data,  it  might 
be  insuflQcient,  and  so  become  useless. 


I  -K-U 


Fig.   100. — Appliance  for  Immediate  Prosthesis  for  Subtotal 
Resection  of  the  Mandible.     (Martin.) 


Moreover,  the  appliance  must  be  joined  to  what 
remains  of  the  original  skeleton  so  intimately  that 
the  latter  and  the  appliance,  in  their  general  contour, 
together  represent  a  similar  form  and  fulfil  a  similar 
function  to  that  of  the  entire  jaw  before  the  appear 
ance  of  pathological  processes. 

The   appliance   must    present    enough   solidity   to 


156  INJURIES  OF  THE  FACE  AND  JAW 

resist  the  cicatricial  tissue.  Lastly,  the  appliance 
must  not  undergo  any  alteration  by  the  contact  of 
scar  tissue,  or  of  the  pus  which  may  itself  engender. 
Thus,  the  material  used  to  make  it  should  fill  two 
most  important  conditions:  it  must  be  aseptic  and 
not  liable  to  corrode. 

The  substance  which  best  fulfils  these  conditions 
is  pure  hardened  rubber,  without  admixture  of  other 
materials  except  sulphur,  which  serves  to  vulcanize 
it.  The  provisional  appliance,  which  should  remain 
in  place  for  the  whole  period  of  cicatrization,  must 


Fig.   ioi. — Appliance  for   Immediate  Prosthesis   for  Partial 
Resection  of  the  Mandible. 

allow  of  the  most  rigorous  antiseptic  treatment  of  the 
operative  field.  To  this  end  Martin's  appliances  are 
provided  with  an  extensive  system  of  canalization, 
destined  to  make  possible  easy  and  frequent  lavage 
of  the  raw  surfaces,  so  as  to  hasten  their  cicatrization. 
But  experience  seems  to  have  shown  that  their  action 
was  entirely  theoretical,  and  that,  on  the  contrary, 
they  offer  to  pus,  food  debris,  and  calcareous  salivary 
salts,  a  shelter  from  which  it  is  difficult  to  dislodge 
them.  So  their  use  has  been  discarded  for  some  years 
already. 


APPLIANCES  FOR  IMMEDIATE  PROSTHESIS    157 

Since  the  provisional  appliance  is  replaced,  at  the 
end  of  a  certain  time,  by  a  final  appliance  of  greater 
finish,  it  must  of  necessity  be  easy  of  removal.     To 
obtain  this  result,  the  appliances  should  be  divided 
into  two  parts  for  the  mandible  and  three  for  the 
maxilla.      One   of   the   most    useful   precautions   to 
expedite  the  removal  of  the  appliances  is  to  make 
them  easy  to  cast  off,   as  we  said  above — that  is, 
they  should  be  carefully  shaped  without  any  con- 
strictions.    For  instance,  we  should  not  imitate  the 
natural  constriction  at  the  neck  of  the  condyle,  for 
the  scar  tissue  will  tighten  on  the  neck  with  a  re- 
sistant sheath  which  will  resist  the  exit  of  the  larger 
condyle.     For  that,  instead  of  imitating  the  natural 
condyle,  it  is  more  valuable  to  leave  nothing  but  a 
small  cylindrical  stump  which  will  easily  slip  out  of 
the  cicatricial  sheath.* 

The  final  apparatus  should  have  the  same  shape 
as  the  first,  except  in  the  case  of  the  posterior  aspect 
of  a  piece  representing  the  upper  jaw. 

If  Martin's  method  has  been  welcomed  with  favour 
in  France,  this  does  not  apply  to  Germany.  In 
fact,  the  surgeons  and  dentists  of  the  German  school, 
with  certain  exceptions,  either  seem  ignorant  of  its 
existence,  or,  like  Boennecken  (of  Berlin)  have 
launched  the  most  violent  criticisms  against  it. 

The  idea  of  placing  in  the  very  depth  of  bleeding 
tissues  a  bulky  foreign  body  runs  counter  to  all 
admitted    dogmata   on   the    treatment    of   surgical 

*  Maurice  Roy,  "  Contribution  to  the  Study  of  Immediate 
and  Late  Prosthesis  in  Resections  of  the  Mandible,"  These 
de  Paris,  1894. 


158  INJURIES  OF  THE  FACE  AND  JAW 

wounds.  Martin's  method  has,  then,  been  con- 
demned at  the  outset  for  the  sake  of  a  purely  dog- 
matic idea,  that  a  foreign  body  in  a  wound  can  only 
lead  to  infection  and  various  comphcations.  Martin 
has  answered  this  adverse  verdict  by  facts,  and 
during  thirty  years  that  his  method  has  been  adopted 
by  him  and  his  pupils  it  has  yielded  nothing  but 
success.  In  reality,  there  is  no  danger  in  applying 
an  aseptic  appliance  to  a  well-drained  wound. 

Again,  Martin's  prosthetic  method  has  been  re- 
proached with  the  excessive  bulk  of  the  appliances 
used.  Nevertheless,  a  bulky  appliance  is  necessary 
to  preserve,  after  the  intervention,  the  integrity  of 
the  shape  of  the  region.  If  the  appliance  has  not 
the  shape  of  the  piece  of  bone  removed,  and  a  mass 
at  least  equal,  if  not  greater,  a  secondary  deformity 
wiU  occur  which  wiU  be  most  stubborn  to  rectify. 
This  principle  is  all  the  more  indispensable  if  more 
extensive  resections — notably  if  these  include  the 
ascending  ramus — are  involved.  These  deformities^ 
which  only  massive  appliances  can  check,  are 
easier  to  prevent  than  to  correct.  People  have  cast 
on  immediate  prosthesis  the  grave  stigma  that  it 
favours  infection  ,of  the  operation  wound,  especially 
in  such  a  septic  locality  as  the  mouth.  However, 
appliances  for  immediate  prosthesis,  if  provided  with 
many  canals,  allow  frequent  irrigation  of  the  whole 
wound  surface,  and  of  all  anfractuosities,.  by  in- 
jecting antiseptic  solutions  under  a  good  pressure. 
These  irrigations  have  been  accused  of  encouraging 
secondary  haemorrhages.  This  is  hardly  probable, 
if  we  take  care  not  to  carry  out  the  lavage  until 


APPLIANCES  FOR  IMMEDIATE  PROSTHESIS    159 

twenty-four  hours  after  operation.  In  about  150 
observations  of  his  own,  Martin  has  only  once  en- 
countered this  accident,  which  seems,  indeed,  rather 
to  depend  upon  a  dyscrasia. 

Finally,  people  have  formulated  against  immediate 
prosthesis  one  last  criticism,  which,  if  it  were  justified, 
would  undoubtedly  be  the  most  serious.  Prolonged 
irrigation  of  the  tissues  being  regarded  as  one  of  the 
occasional. causes  of  malignant  tumours,  it  has  been 
said  in  reproach  of  such  appliances  (immediate  pros- 
theses) that  they  favour  the  recurrence  of  neoplasms 
by  the  irritation  of  the  wound  in  whose  depth  they 
are  fixed.  Experience  does  not  seemingly  confirm 
this  idea;  and,  for  our  part,  in  our  personal  practice 
we  have  never  seen  recurrences  clearly  to  be  blamed 
on  a  prosthesis.  It  is  with  justice  that  CI.  Martin 
declaims  forcibly  against  this  notion: 

"  I  have  done  justice  to  these  accusations  in 
showing  by  the  facts  that,  when  a  recurrence  occurs, 
it  is  not  manifest  any  sooner  than  in  the  case  where 
we  have  not  placed  a  prosthesis;  and  that  after  two, 
three,  or  even  four  recurrences  the  immediate  pros- 
thesis has  had  a  full  success,  since  the  tumour  in 
these  cases  has  not  recurred.  What  encourages  the 
recurrence  is  a  not  bold  enough  resection,  extending 
not  widely  enough  beyond  the  apparent  limits  of 
the  tumour.  At  this  day  several  surgeons  of  Lyons, 
whom  I-  have  been  able  to  convince  of  the  advan- 
tages and  harmlessness  of  the  method,  are  persuaded' 
that,  thanks  to  it,  one  can  without  inconvenience 
increase  the  extent  of  the  loss  of  substance  without 
being  afraid  of  going  very  wide  of  the  limits  of  the 


i6o  INJURIES  OF  THE  FACE  AND  JAW 

growth.  And  experience  has  shown  that  with  large 
excisions  recurrences  are  much  less  frequent.  So 
that  the  prosthetic  appliances  not  merely  do  not 
encourage  recurrences,  but,  on  the  contrary,  often 
help  to  prevent  them  by  enabling  one  to  make  large 
bony  gaps  without  incurring  any  disability."* 

In  Germany,  immediate  prosthesis  used  after 
resections  involving  the  mandible  do  not  as  a  rule 
have  any  relation  to  Martin's  method,  and  depend 
on  a  quite  different  principle. 

Instead  of  replacing  the  resected  piece  of  bone  by 
a  foreign  body  of  the  same  size  and  shape,  and 
leaving  the  wound  open,  they  strive,  on  the  contrary, 
in  Germany,  to  maintain  the  fragments  with  the  help 
of  the  smallest  possible  appliances,  which  have  been 
named  "  bandages,"  These  splints  constitute,  in- 
deed, retention  appliances  rather  than  restoring 
prostheses.  The  fear  of  infection  which  rightly 
holds  sway  in  the  practice  of  German  surgeons,  but 
which  is  hardly  justified  in  this  particular  case, 
causes  them  to  deprive  their  patients  of  the  advan- 
tages of  immediate  prosthesis  according  to  CI.  Martin's 
method. 

Sauer's  appliance  is  the  first  of  which  the  applica- 
tion has  been  published  in  Germany.  It  consists  of 
a  metal  arc  interposed  between  the  fragments,  and 
fixed  at  either  end  to  the  remaining  teeth.  When 
there  are  no  teeth,  the  extremities  of  this  splint, 
altered  to  a  forked  shape,  sit  astride  the  cut  ends  of 
the  bone.  The  two  branches  correspond  to  the 
anterior   and   posterior   faces   of   the   fragments,    to 

*   CI.  IMartin,  Rapport  au  Cong,  de  ^Madrid,  1903,  p.  82. 


APPLIANCES  FOR  IMMEDIATE  PROSTHESIS     i6i 

which  they  are  fixed  by  metal  wires.  The  wound 
is  then  treated  by  swabbing  until  cicatrization  is 
complete.  At  this  moment  the  metal  bandage  is 
removed  and  replaced  by  a  permanent  apparatus. 
If  only  one  fragment  remains,  Sauer  adopts  the 
wearing  of  an  inclined  plane  (see  the  volume  on 
Orthodontia)  to  prevent  its  deviation.  Hahl,  Boen- 
necken,  Tenison-Lyons  use  splints  similar  to  those 


Fig.   1 02. — Hausniaiinsche's  Appliance. 

of  Sauer,  and  formed  essentially  of  a  simple  metallic 

wire.     They  cannot  be  fixed  to  the  teeth  when  there 

are   very   few   of   these   remaining;    one   molar,    for 

instance,  acting  as  point  d'appui  on  each  fragment, 

cannot  resist  the  pull  of  the  scar  tissue.     But  the 

most  serious  criticism  which  one  can  level  at  these 

appliances  is  that  they  offer  no  resistance  to  the 

down-sinking   of   the   soft    parts   between   the   two 

fragments,  when  these  are  kept  at  a  distance  only  by 

a  simple  metal  wire. 

II 


1 62  INJLRIES  OF  THE  FACE  AND  J  AW 

Deformity  is  inevitable,  for  iodoform  gauze  packed 
into  the  wound  can  only  remedy  it  to  a  very  slight 
degree.  Moreover,  proloiiged  tamponage  of  opera- 
tion cavities  in  communication  with  the  mouth  or 


Fig.  103. — Stoppany's  Appliance. 

nose  constitute  a  detestable  plan  of  treatment;  for 
nothing  can  more  encourage  its  infection  and  prolong 
the  period  of  its  epithelialization.  The  use  of  tem- 
porary splints  instead  of  bulky  appliances,  so  far 
irom    being    a    guarantee    against    infection,    tends 


APPLIANCES  FOR  IMMEDIATE  PROSTHESIS     163 

therefore  to  the  opposite  result,  if  simultaneously  one 
goes  in  for  prolonged  swabbings  of  the  wound  with 
gauze,  whether  iodoform  or  plain. 

Hausmannsche's  appliance  consists,  not  of  a  wire, 
but  a  band  of  metal,  pierced  by  holes  and  fixed  to 
the  fragments  by  silver  wire  ligatures.  It  is  clear 
that  this  band  is  better  than  Sauer's  wire,  for  the 
former  gives  to  the  soft  parts  a  support  in  the  antero- 
posterior plane  (Fig.  102).     With  the  idea  of  holding 


Fig.   104. — Boennecken's  Appliance. 

up  the  tissues  equally  in  the  coronal  plane,  Partsch 
has  modified  the  splint  of  Hausmannsche  by  covering 
its  edges  with  vulcanized  rubber. 

Stoppany  has  made  an  appliance  of  a  metal  gutter 
of  the  size  and  shape  of  the  lower  jaw,  pierced  by 
holes.  This  gutter,  opening  upwards,  is  fixed  at  its 
ends  to  the  bony  fragments,  and  its  concavity  is 
packed  with  iodoform  gauze  (Fig.  103).  Here,  then, 
we  have  a  bulky  appliance,  which,  however,  presents 
all  the  drawbacks  caused  by  prolonged  tamponage 


1 64  INJURIES  OF  THE  FACE  AND  JAW 

of  buccal  wounds.  Fritzsche*  used  a  piece  of  cast 
tin  fixed  to  the  jaw  by  the  intervention  of  supports 
implanted  in  the  bone ;  the  tin  block  and  the  supports 
were  linked  together  by  pins,  so  that  the  piece  of 
tin  could  be  removed  and  replaced  at  will,  for  wash- 
ing out.  In  any  case,  Fritzsche  thus  approximates 
in  general  principles  to  CI.  Martin's  method. 

Delair  has  recommended  the  use  of  porcelain  to 

make  appliances  for  immediate  prosthesis  of  the  jaw.t 

Delair's  porcelain  block  has  the  twofold  disadvantage 

of  preventing  lavage  of  the  wound  (for  the  piece  is 

not  canaliculized,  and  is  not  in  this  case  removable, 

as  is  Fritzsche's  tin  block),  and  of  not  being  able  to 

be  retouched  as  easily  as  a  block  of  vulcanized  rubber 

(porcelain   being   infinitely   harder   than   vulcanite). 

Moreover,   Delair  fixes  his  appliance  with  bolts,   a 

system  of  retention  excellent  for  internal  prosthesis, 

because  of  its  great  solidity,  but  less  desirable  for 

immediate  prosthesis,   since  after  a  few  weeks  the 

appliance   must    be   removed   to    give   place   to   its 

permanent  successor.     Now,  a  contrivance  fixed  by 

bolts   is   vastly   more   difficult   of   removal   than   is 

one   fixed   by   screws    on   only    one    surface   of    the 

jaw. 

Finally,  let  us  conclude  this  rapid  review  of  the 
various  attempts  at  immediate  prosthesis  by  quoting 

*  Curt  Fritzsche,  "  Study  of  Various  Mandibular  Pros- 
theses, and  Description  of  a  New  Artificial  Jaw  "  (Rapport  a 
la  xvii^  assemblee  des  dentistes  de  Saxe  a  Leipsig,  i6  Juin, 
1901;  Deutsche  Monatsschrift  fur  Zahnh.,  p.  262,  Juin,  1902, 
et  Deutsche  Zeitschrift  fiir  Chirurgie,  1901,  Ixi.). 

t  Delair,  "  Prosthesis  for  Bony  Parts  in  Porcelain  " 
{Odontol.,  30  Janv.,  1903,  p.  49.) 


APPLIANCES  FOR  IMMEDIATE  PROSTHESIS     165 

Martin's  opinion  on  one  of  the  most  recent,  Schroeder's 
gutter :  * 

"  The  most  recently  described  in  Germany,  and 
in  my  opinion  one  of  the  best  appliances,  is  that 
which  was  published  in  1901  by  H.  Schroeder,  It 
has  several  points  of  resemblance  to  Stoppany's,  but, 
instead  of  being  in  metal,  it  is  made  of  gum-elastic. 
It  is  like  a  gutter,  opening  this  time,  not  upwards, 
but  backwards;  and  its  concavity  is  packed  with 
iodoform  gauze.  It  forms  a  sort  of  shell,  of  which 
only  the  outer  and  lower  aspects  reproduce  the  shape 
of  the  jaw,  holding  out  the  integuments.  The  upper 
border  of  the  piece  is  perforated  with  holes  for  at- 
taching the  alveolar  segment  (of  this  plan  Schroeder 
is  still  a  partisan).  The  arrangement  is  kept  in  place 
by  bilateral  ligatures.  Schroeder,  in  the  construction 
of  his  appliance,  has  been  dominated,  like  his  German 
colleagues,  by  the  notion  of  being  able  to  watch  the 
surface  of  the  wound,  in  view  of  a  possible  recurrence. 
Now,  this  latter  as  a  rule  does  not  occur,  or  is  not 
recognizable  until  after  some  weeks — that  is,  at  a 
period  when  provisional  apparatus  is  commonly 
removed.  The  final  appliance  gives  every  guarantee 
as  regards  this  supervision.  The  caution  of  the 
German  school  in  this  regard  seems,  then,  to  me 
overdone,  as  also  the  fear  lest  the  appliance  come 
into  contact  with  the  cut  surfaces;  for  this  latter 
condition  is  not  at  all  often  realized."! 

*  Schroeder,  "  Facial  Prosthesis:  Mode  of  applying  Den- 
tal Prosthesis  to  the  Face,  with  Special  Reference  to  Immedi- 
ate Prosthesis  of  the  Jaws  after  Resection  "  {Correspondenz 
Blatt  fur  Zahartze,  Juillet,  1901). 

f  CI.  Martin,  Rapport  au  Cong,  de  Madrid,  1903,  p.  90. 


166  INJURIES  OF  THE  FACE  AND  JAW 

To  sum  up:  appliances  for  immediate  prosthesis 
of  the  lower  jaw  fall  into  three  groups: 

1.  Appliances  constituted  by  a  hoop  or  arc,  holding 
the  fragments  apart,  but  offering  no  support  to  the 
soft  parts  (Sauer,  Boennecken,  Tenison-Lyons). 
They  have  the  fault  that  they  only  correct  the  de- 
formity to  a  moderate  degree,  and  do  not  resist 
cicatricial  contraction. 

2.  Appliances  consisting  of  a  sheet  of  greater  or 
less  thickness  (Hahl,  Hausmannsche,  Partsch).  They 
have  the  advantage  over  the  first  group  that  they 
sustain  the  soft  parts  better,  but  their  bulk  is  in- 
sufficient to  keep  the  necessary  space  for  the  per- 
manent apparatus. 

3.  Appliances  made  in  the  shape  of  a  fenestrated 
gutter  (Stoppany,  Schroeder),  or  in  a  solid  form: 
tin  (Fritzsche),  porcelain  (Delair),  rubber  (Martin). 
They  have  the  advantage  of  replacing  the  segment 
of  bone  removed  as  exactly  as  possible  in  size  and 
shape,  and  of  thus  preserving  the  space  necessary  for 
the  permanent  apparatus. 

Among  this  latter  group,  appliances  made  accord- 
ing to  CI.  Martin's  principles  are  certainly  the  most 
perfect.  They  have  given,  in  the  course  of  a  long 
experience,  the  most  constant  results;  for  they  satisfy 
the  following  conditions,  which  should  always  be  our 
aim  in  immediate  prosthesis: 

1.  The  appliance  should  correspond  in  shape  and 
size  to  the  piece  of  bone  resected. 

2.  It  should  be  fixed  with  sufficient  firmness  to 
prevent  spontaneous  movement,  but  meanwhile 
sufficiently  lightly  to  enable  it  to  be  removed  easily. 


DESCRIPTION  OF  APPLIANCES  167 

In  this  case  the  best  mode  of  retention  Ues  in  screws 
applied  to  the  external  table  of  the  jaw. 

3.  The  appliance  should  be  made  of  a  substance 
as  compact  as  possible,  easy  to  sterilize,  and  resistant 
enough  to  oppose  cicatricial  retraction.  This  sub- 
stance must  be  tolerated  by  the  tissues  and  unaffected 
by  organic  fluids.  Its  consistence  must  allow  the 
piece  to  be  pared  down  and  altered  quickly  and  easily 
at  the  very  moment  of  operation,  so  that  its  applica- 
tion does  not  entail  for  the  patient  the  inconvenience 
and  danger  of  a  prolonged  intervention. 

Vulcanized  rubber,  in  fulfilling  all  these  conditions, 
constitutes  at  the  present  day  the  material  of  choice 
for  immediate  prosthesis. 


CHAPTER  V 

APPLIANCES  FOR  IMMEDIATE  PROSTHESES  FOR 
THE  LOWER  JAW 

Description  of  Appliances  —According  to  the  cases 
and  views  of  the  surgeon,  there  will  remain,  after 
operation,  either — 

1.  The  greater  part  of  the  bone,  comprising  the 
posterior  portions  and  the  ascending  rami; 

2.  Only  one  ascending  ramus;  or 

3.  Nothing.  The  mandible  has  been  sacrificed  in 
its  entirety,  and  the  appUance  thereafter  rests  only 
on  the  soft  tissues. 

Condition  i:  Partial  Resection. — The  appliance  has 
only  two  parts,  the  body  and  the  alveolar  border. 


i68  INJURIES  OF  THE  FACE  AND  JAW 

The  fixation  to  the  remaining  bone  is  accompHshed 
by  means  of  metal  plates  (sheet  steel,  platinum); 
the  internal  plate,  fairly  large,  bears  no  screw,  and 
serves  to  prevent  the  inward  displacement  of  the 
fragments.  The  external,  narrower,  takes  small 
screws,  which  are  inserted  into  the  body  of  the  bone. 

Condition  2  :  Extensive  Resection. — The  posterior 
parts  of  the  bone,  the  ascending  rami,  or  at  least  the 
condyles,  remain.  The  appliance  is  made  to  re- 
present a  whole  mandible,  and  then  reduced  to  the 
extent  of  the  bone  spared.  Springs  are  indis- 
pensable; in  placing  them  we  allow  for  the  irregular 
movements  of  the  lower  jaw.  If  one  end  of  the 
appliance  is  pointed  to  fit  into  the  condylar  notch, 
the  other  end  will  consist  of  plates  to  grip  the  ascend- 
ing ramus  of  the  other  side. 

For  appliances  of  a  considerable  length,  we  divide 
the  artificial  jaw  at  the  symphysis  as  soon  as  it  is 
vulcanized,  so  as  to  be  able  to  remove  it.  To  insure 
the  union  of  the  separate  parts,  we  place  on  the 
front  part  of  the  piece  a  metal  plate,  which  is  fixed 
into  the  rubber  by  means  of  a  screw.  If  the  insertion 
of  the  genio-glossi  has  been  destroyed,  we  pass  a 
metal  wire  through  the  tongue  and  attach  it  to  the 
appliance. 

Condition  3  :  Complete  Resection. — There  has  never 
been  a  case  of  immediate  prosthesis  applied  after 
total  resection  of  the  mandible.  Nevertheless, 
Martin  published  one  observation  where  nearly  the 
whole  jaw  was  affected  (except  one  condyle  and  one 
coronoid  process),  and,  basing  his  opinion  on  this, 
considered  that  the  placing  of  this  class  of  apparatus 


MEANS  OF  RETENTION 


169 


should  not  present  much  greater  difficulties  than  in 
other  cases. 

The  alveolar  border  of  the  provisional  appliance 
carries  no  teeth.  In  the  final  apparatus,  on  the 
contrary,  these  are  provided.  It  is  of  hardened 
rubber,  and  carries  at  its  lower  border  two  rods, 
sliding  with  hardly  any  friction  in  the  lower  jaw. 


Fig.   105. — Immediate  Prosthetic  Appliance  for  the  Lower 
Jaw.     (Martin.) 

Thus  it  can  be  removed  and  modified  according  to 
the  requirements  of  the  articulation. 

Means  of  Retention. — These  vary  with  the  case  and 
the  parts  involved.     We  can  thus  divide  them: 

(a)  Methods  of  fixation  which  immobilize  the 
apparatus:  screws,  pins,  platinum  rods. 

{b)  Means  of  retention  properly  so  called,  which 
act  by  simply  reinforcing:  hooks,  wings,  springs. 


I70  INJURIES  OF  THE  FACE  AND  JAW 

Screws,  pins,  and  platinum  rods,  which  by  their 
head  penetrate  the  jaw  through  and  through,  and 
at  their  tail  end  are  curved  or  fixed  with  a  nut,  have 
been  used.  We  have  just  seen  that  the  apparatus 
should  carry  two  external  plates  pierced  by  holes 
through  which  pass  screws  fixed  into  the  bone,  and 
one  internal  plate  placed  against  the  inner  side  of 
the  fragment. 

To  assure  the  good  working  of  the  jaw  and  hold 
the  appliance  more  solidly,  we  avail  ourselves  of 
springs,  and  then  a  palatine  plate  is  required;  these 
springs  are  spirals,  such  as  we  use  for  ordinary 
prosthesis,  fixed  by  spring-holders.  Martin  has 
altered  certain  features  in  their  action.  In  fixing 
these  springs  to  the  dentures,  one  usually  places  them 
on  a  point  which  forms  the  centre  of  gravity  of  the 
apphance ;  their  role  consists  in  keeping  the  apparatus 
in  place  during  the  movements  necessary  for  speech 
and  mastication.  Martin  made  use  of  them  by 
immobilizing  their  upper  end,  to  limit  the  movements 
of  depression  of  the  jaw,  and  to  urge  the  appliance 
backwards  and  upwards  during  this  movement. 

When  the  fragment  left  intact  by  the  resection 
carries  teeth,  it  is  well  to  use  them  as  a  point  of 
attachment,  by  fitting  thereto  hooks,  sheets,  or 
crowns.  In  certain  cases  it  may  happen  that  the 
appliance,  only  resting  on  soft  tissues,  may  be  in- 
sufficient to  resist  the  lateral  displacement  of  the 
remaining  fragment.  We  remedy  this  with  the  help 
of  two  vertical  wings  fixed,  the  one  to  the  upper,  the 
other  to  the  lower  appliance.  [The  author  here 
implies  that  the  hooks,  sheets,  or  crowns,  or  else  what 


MEANS  OF  RETENTION  171 

we  call  a  "  cap-splint,"  have  been  fixed  to  both  upper 
and  lower  teeth  on  the  side  of  the  remaining  mandib- 
ular fragment — Tr.]  These  wings  generally  have 
the  shape  of  a  quarter-circle,  and  are  arranged  so 
as  to  glide  one  on  the  other  in  the  up-and-down 
movements  of  the  jaw;  the  lower  passing  outside 
the  upper,  the  inner  face  of  the  former  is  in  relation 
with  the  outer  face  of  the  latter  (see  Figs.  22,  23,  24). 

Their  height  must  be  adequate ;  for  when  the  mouth 
is  open,  the  juxtaposition  of  the  two  wings,  near 
their  free  edges,  is  to  check  all  movements  of  lateral 
displacement  and  guide  the  low^ering  movement. 
To  prevent  too  great  friction  against  the  whole 
surface  of  the  plane,  we  can  stamp  on  the  upper 
plane  {i.e.,  wing)  a  boss  representing  the  segment  of 
a  circle  whose  centre  is  the  temporo-maxillary  joint; 
so  that  friction  is  limited  to  the  surface  of  this  boss, 
which  is  about  i  mm.  wide  (Gillard). 

Martin  has  lately  published  a  new  process,  which 
he  employs  when  the  resection  affects  the  body  of 
the  mandible,  including  part  or  all  of  the  ascending 
ramus.  In  his  case,  only  one  end  could  be  fixed  to 
the  remaining  fragment;  the  other  free  end  was 
uncomfortable,  and  could  have  even  hindered  the 
movements  of  the  lower  jaw.  He  altered  his  plan 
of  fixation  as  follows:  To  that  part  of  the  appliance 
which  had  to  fit  against  the  remaining  fragment  he 
fixed  three  plates.  One,  attached  to  its  inner  aspect, 
simply  rested  against  the  bony  fragment.  The  other 
two  were  attached  to  the  outer  aspect  of  the  appliance. 
Of  these  two  plates,  that  which  was  screwed  to  the 
upper  part  of  the  bone  had  to  be  screwed  on  to  the 


172  INJURIES  OF  THE  FACE  AND  JAW 

lower  part  of  the  appliance;  whereas  that  attached 
to  the  lower  part  of  the  bone  joined  the  upper  part 
of  the  appliance.  This  simple  contrivance  of  crossed 
plates  enables  one  to  dispense  with  the  gutter  to 
enclose  the  teeth  remaining  on  the  fragment — such 
a  gutter  had  until  then  been  employed — and  makes 
the  retention  of  the  apparatus  much  firmer. 

As  in  all  cases  where  appliances  of  this  sort  are 
not  placed  between  two  fragments,  and  where  they 
are  held  by  one  solitary  fragment,  it  will  be  wise  to 
employ  the  small  wings  previously  described.  They 
play  their  part  of  preventing  the  displacement  of 
the  fragment  and  keeping  it  in  its  normal  position. 
After  we  have  found  a  sufficiently  firm  support  in 
the  means  of  attachment,  the  means  oi  fixation  must 
be  dispensed  with ;  and  it  is  not  always  easy  to  remove 
the  screws,  owing  to  the  condensation  of  bone.  It 
is  no  good  thinking  of  unscrewing  them;  we  must 
force  them  out  by  leverage  on  the  metal  bands  with 
an  instrument  introduced  under  the  mucosa — a  strong 
rugine,  for  instance  (Maurice  Roy). 

When  the  surgeon  has  respected  the  periosteum 
and  left  it  adherent  to  the  muscular  tissue,  we  must 
arrange  in  the  apparatus  a  sort  of  sheath  for  this 
periosteum  and  for  the  new  bone  which  will  be 
formed.  Step  by  step  with  this  new  formation  we 
must  modify  the  appliance. 

Construction  of  the  Appliances. 

The  fashioning  of  appliances  for  immediate  pros- 
thesis has  certain  characteristics  common  to  that  of 
all    prosthetic    dental    appliances.     None    the    less, 


CONSTRUCTION  OF  THE  APPLIANCES       173 

there  are  certain  original  details  which  it  is  useful 
to  emphasize. 

A.  First  or  Provisional  Appliance — Taking  Im- 
pressions.— Strictly  speaking,  our  concern  is  to  take 
measurements;  for  an  impression  of  a  part  not  yet 
exposed  cannot  be  taken.  The  measurements  should 
give  approximately  the  shape  of  the  appliance  which 
is  to  replace  the  bony  segment  removed.  For  this, 
we  procure  a  jaw  from  a  skeleton  having  nearly  the 
same  shape  and  size  as  that  of  the  subject.  We 
then  measure  the  width  of  the  upper  dental  arch 
of  the  patient  and  the  height  of  the  healthy  portion 
of  his  mandible.  Thus  we  get  sufficient  data  to  make 
the  provisional  appliance. 

Mould  in  Wax. — On  these  measurements  we  make, 
in  wax,  a  jaw  resembling  the  model  chosen.  We 
mould  in  several  parts  the  natural  jaw;  these 
parts  give  the  hollow  (or  negative)  mould.  In  this 
we  cast  wax,  thus  obtaining  a  jaw  of  the  type 
selected. 

Modifications. — -This  jaw  in  wax  is  then  altered, 
according  to  requirements  and  measurements.  The 
alveolar  border,  which,  after  the  moulding,  is  fur- 
nished with  teeth,  is  assembled  into  one  piece.  By 
separating  the  alveolar  margin  from  the  body  of  the 
jaw  with  a  steel  spatula  (preferably  heated),  we  get 
the  two  pieces  of  the  mandible. 

Internal  Canals. — If  we  wish  to  furnish  the  appli- 
ance with  these,  so  as  to  irrigate,  we  proceed  in  the 
following  manner:  The  body  of  the  jaw  is  traversed 
throughout  its  whole  length,  when  it  is  in  wax,  by 
a  zinc  tube  placed  in  the  midst  of  its  thickness;  the 


174  INJURIES  OF   THE  FACE  AND  JAW 

tube  exits  at  the  two  ends  of  the  piece.  In  fact, 
it  should  project  beyond  the  latter  for  about  2  cm. 
These  two  ends  of  the  tube  must  be  sunk  in  the 
plaster,  so  as  to  keep  the  whole  tube  in  a  settled 
position  during  the  removal  of  the  wax  and  the  sub- 
stitution of  rubber.  At  the  level  of  the  ascending 
rami  we  add  to  the  vertical  tube  two  vertical  pro- 
longations, also  tubular,  which,  with  the  same  object, 
emerge  at  the  end  of  the  condyle  and  coronoid  pro- 
cess. The  zinc  tube  should  be  treated  with  Spanish 
white  on  its  inside,  to  prevent  during  its  vulcaniza- 
tion the  penetration  of  rubber,  which  would  choke 
the  tube  and  make  irrigation  impossible. 

Flashing. — Having  thus  prepared  the  piece,  we 
flask  it  as  for  an  ordinary  apparatus.  Only,  in  view 
of  the  bulk  of  the  appliance,  we  require  a  special 
flask.  Martin  uses  a  series  of  washers,  2-5  cm.  in 
height,  one  on  top  of  the  other;  according  to  the 
size  of  the  apparatus,  he  puts  in  fewer  or  more  of 
these.  M.  Roy  employs  a  more  simple  flask  con- 
sisting of  a  metal  block,  fairly  large,  with  a  cover 
similar  to  that  of  an  ordinary  flask. 

Filling. — To  prevent  the  porosity  of  the  appliance, 
we  make  fragments  of  rubber  permeate  it  as  far  as 
possible.  These  tiny  pieces  should  be  of  hardened 
rubber,  carefully  cleansed;  and  their  object  is  to 
fuse  intimately  with  the  rubber  which  we  shall 
vulcanize. 

Vulcanization. — A  most  important  procedure  in 
making  these  appliances.  As  they  are  very  bulky 
and  surrounded  with  much  plaster,  one  must  raise 
the  temperature  slowly,  and  take  an  hour  to  arrive 


CONSTRUCTION  OF  THE  APPLIANCES       175 

at  145°  C.  This  point  reached,  do  not  exceed  it, 
and  keep  the  vulcanization  at  this  degree  of  heat  for 
four  or  five  hours.  Having  finished  the  vulcanization, 
let  the  flask  cool  in  the  vulcahizer. 

Repairing. — The  piece  is  repaired;  then  we  cut 
it  in  two  in  the  middle  line.  After  that  we  remove 
the  zinc  tubes  by  placing  the  piece  in  water  to  which 
sulphuric  acid  has  been  added.  There  now  remains, 
in  the  place  occupied  by  the  tubes,  a  canal  traversing 
the  appliance  from  one  end  to  the  other.  The  two 
segments  are  then  joined  by  means  of  a  steel  plate 
screwed  on  to  the  appliance.  We  re-establish  the 
continuity  of  the  irrigation  canal  (previously  divided 
by  a  vertical  saw-cut,  as  just  mentioned)  by  means 
of  a  metal  tube,  which  joins  the  two  cut  ends  of  the 
canal,  and  simultaneously  helps  to  support  the  two 
parts  of  the  piece.  At  the  upper  part  of  the  appli- 
ance, at  a  point  corresponding  nearly  to  one  of  the 
canines,  where  the  central  canal  lies  near  to  the 
alveolar  border,  we  place  a  small  metal  tube  which 
has  a  gentle  slope  from  above  downwards  and  from 
without  inwards.  Its  lower  end  enters  the  central 
canal.  To  its  free  end  is  fitted  the  rubber  tube, 
which  emerges  from  the  mouth  and  facilitates  irriga- 
tions. 

On  the  lower  border  of  the  appliance  we  make, 
wdth  a  drill,  a  series  of  holes  communicating  with 
the  main  canal;  by  these  openings  the  adjacent  raw 
surfaces  will  receive  antiseptic  washes.  Later,  when 
the  irrigation  canals  become  useless,  one  can  block 
them  up  by  injecting  into  them  a  little  iodoform 
wax. 


176  INJURIES  OF  THE  FACE  AND  JAW 

B.  Second  or  Permanent  Appliance. — Whatever 
this  may  be,  it  is  less  beset  with  difficulties  than  the 
provisional  appliance.  It  should  have  the  same 
dimensions,  based  on  the  mould  which  has  served 
for  the  former.  But  since  cicatrization  has  modified 
the  buccal  floor,  it  is  useful,  while  taking  the  im- 
pression, to  keep  the  fragments  apart  by  an 
apparatus. 

There  are  no  longer  irrigation  canals,  for  the 
appliance  is  removable  and  can  be  cleaned.  There 
is  no  longer  a  vertical  division,  at  any  rate  in  the 


Fig.   io6. — Final  Apparatus  for  the  Lower  Jaw.     (Martin.) 

less  considerable  appliances.  But  if  the  piece  is 
bulky,  it  is  useful  to  make  a  vertical  median  cut, 
closed  by  a  spring  resembling  the  catch  of  a  bracelet. 
The  points  for  bony  attachment  are  dispensed  with. 
The  internal  prolongations  are  kept,  but  they  are 
made  of  the  same  substance  as  the  appliance. 
Instead  of  natural  brown  rubber,  one  can  use  rubbers 
variously  coloured,  so  as  to  harmonize  the  colours 
from  the  aesthetic  point  of  view.  The  alveolar 
border  is  furnished  with  teeth  which  articulate  with 
those  of  the  upper  jaw  (Fig.  io6). 


GENERALITIES  177 


CHAPTER  VI 

APPLIANCES  OF  IMMEDIATE   PROSTHESES   FOR 
THE  UPPER  JAW 

I.  Generalities. 

The  advantage  of  immediate  prosthesis  for  the  upper 
jaw  are  fewer  and  less  important  than  for  the  lower 
jaw.  However,  in  giving  a  point  d'appui  to  the  soft 
parts,  the  appliance  prevents  the  deformity  con- 
secutive to  scarring.  It  permits  of  feeding  directly 
after  cicatrization,  and  facilitates  speech.  One 
should,  accordingly,  make  a  practice  of  immediate 
prosthesis  in  all  cases  of  resection  of  the  upper 
jaw. 

We  proceed  as  for  the  mandible.  That  is  to  say 
that,  immediately  after  the  resection,  we  fit  an 
apparatus  made  beforehand  according  to  certain 
data  provided  by  the  parts  to  be  replaced,  and 
obtained  before  the  operation.  As  a  rule  this  mould 
only  gives  rough  indications  of  the  exact  dimensions 
which  the  appliance  should  have,  but  in  such  re- 
sections as  are  only  unilateral  the  lower  dental  arch 
and  teeth  of  the  sound  side  are  used  to  obtain  the 
necessary  measurements.  If  the  upper  jaw  carries 
no  teeth,  the  bare  dental  arch  suffices  to  indicate 
the  dimensions  of  the  appliance.  The  height  is 
indicated  by  a  line  drawn  from  the  necks  of  the 
teeth  (or  the  alveolar  margin)  on  the  opposite  side, 
to  the  orbital  floor,  without  reckoning  the  soft 
parts. 

12 


178  INJURIES  OF  THE  FACE  AND  JAW 

II.  Description  of  Appliances. 

They  are  less  numerous,  and  admit  of  fewer  modi- 
fications, than  the  appUances  described  for  the 
mandible.  The  points  of  attachment  are  less  com- 
plicated and  play  a  less  important  part,  since  the 
apparatus  is  fixed  in  immovable  masses,  which  make 
it  easier  to  fasten  them.  Owing  to  the  height  which 
they  may  have,  a  transverse  division  into  two  parts 
is  sometimes  necessary.  Just  as  in  the  case  of  the 
mandible,  one  can  equip  them  with  a  system  of 
central  canalization  with  multiple  openings,  which, 
at  any  rate  in  early  stages,  allows  of  rigorous  anti- 
sepsis and  the  omission  of  dressings.  The  appliance 
is  of  hardened  rubber,  and  represents  a  greater  or 
less  segment  of  the  maxillary  structure.  It  is  divided 
into  two  parts.  One  constitutes  the  velum,  the  hard 
palate,  and  dental  arch;  it  is  horizontal.  The  other, 
vertical,  includes  the  whole  anterior  surface  of  the 
upper  jaw,  the  nasal  and  malar  bones,  and  the  orbital 
floor. 

The  portion  corresponding  to  the  dental  arches  is 
of  hardened  rubber,  so  as  to  be  able  to  be  altered 
according  to  the  needs  of  the  articulation.  The 
palatine  vault  and  the  velum,  when  the  latter  is 
concerned,  are  in  all  cases  complete  [i.e.,  bilateral, 
a  replica  of  the  whole  roof  of  the  mouth — Tr.]. 
This  horizontal  part  is  destined  to  replace  the  portion 
removed  on  one  side;  and,  on  the  other  side,  to  cover 
the  remains  [i.e.,  the  remains  of  soft  and  hard  palates 
on  the  sound  side — Tr.],  so  as  to  have  no  solution 
of   continuity.      For   the   rest,    the   margin   on   the 


DESCRIPTION  OF  APPLIANCES 


179 


healthy  side  is  furnished  with  hooks  to  fix  the  appli- 
ance to  the  remaining  teeth  (see  p.  20,  Figs.  9  and  10, 
for  the  type  of  hooks  to  be  used) ;  if  these  are  not 
enough,  we  can  supplement  them  with  springs  taking 


Fig.   107. — Provisional^Applianct   for  the  Upper     Jaw. 

(Martin.) 

their  purchase  from  the  mandible.  The  hindmost 
part  of  the  horizontal  portion  always  ends  in  a  sheet 
of  soft  rubber,  which  lends  itself  better  than  hard 
rubber  to  the  movements  of  the  palatine  velum.  At 
the  foremost  part  of  the  horizontal  portion,  repre- 


i8o  INJURTES  or   THE  FACE  AND   JAW 

senting  the  dental  arch,  we  arrange  an  opening,  to 
which  is  fitted  the  tube  to  serve  for  lavage,  supposing 
that  the  appliance  possesses  a  canal  system  analogous 
to  that  described  for  the  mandible.  Some  large 
lateral  openings  allow  of  the  exit  of  the  fluids.  The 
horizontal  part  fits  on  to  the  vertical  portion  of  the 
piece  representing  the  external  face  of  the  bone. 
A  pair  of  tubes  suffices  to  join  up  the  canals  of  the 
two  pieces,  simultaneously  contributing  to  their 
firmness. 

The  parts  corresponding  to  the  ascending  ramus 
of  the  maxilla,  and  to  the  malar  bone,  being  larger 
than  the  part  below,  and  therefore  not  easy  of 
removal,  we  divide  this  upper  portion  into  two, 
by  a  vertical  saw-cut  joining  the  middle  of  the 
orbital  floor  to  the  first  or  second  premolar.  These 
two  segments  of  the  upper  piece  are  hinged  at  their 
line  of  intersection.  Then,  by  a  metal  rod  passed 
through  them,  they  can  be  kept  in  close  relation, 
not  only  with  each  other,  but  also  with  the  lower 
piece.  By  withdrawing  this  rod,  nothing  is  simpler 
than  to  remove  the  three  parts  of  the  appliance. 

All  that  portion  of  the  appliance  which  corresponds 
to  the  posterior  region  of  the  bone  is  left  wide  open, 
because  it  suffices  to  keep  the  soft  parts  in  place, 
leaving  the  deeper  tissues  to  cicatrize  in  their  own 
way.  Thus,  there  is  no  necessity,  as  there  is  in 
prostheses  for  the  lower  jaw,  to  make  an  appliance 
equal  in  volume  to  the  piece  of  bone  resected. 

"  The  anatomical  conditions  presented  to  us," 
writes  Martin,  "  after  a  resection  of  the  maxilla,  are 
utterly  different   from  those  which  exist   after   re- 


FIXATION  i8i 

sections  of  the  mandible.  Whereas  the  latter,  very 
mobile,  tends,  under  the  influence  of  muscular  con- 
traction and  cicatricial  retraction,  to  deviate,  the 
upper  jaw,  deeply  embedded  in  the  bones  of  the  face 
and  of  the  cranial  base,  leaves  after  its  ablation  a 
vast  cavity  whose  fixed  bony  walls  cannot  come 
together  and  scar  over.  This  cavity  can  only  shrink 
by  the  depression  of  the  facial  integuments.  For 
the  rest,  the  roomy  communication  between  mouth, 
nasal  fossae,  and  pharynx,  involves  in  its  train  grave 
functional  troubles — disabilities  of  mastication,  swal- 
lowing, and  speech.  Often  the  cBsthetic  deformity  is 
hut  little  marked,  and  it  is  above  all  the  functional 
changes  which  predominate.  [The  italics  are  the 
Translator's.]  Hence  the  paramount  importance  of 
prosthesis  for  these  patients.  The  arrangement  in 
front  of  the  vertical  part  leaves  free  the  cavity 
produced  by  the  bony  ablation.  The  latter  can  thus 
cicatrize  freely  without  any  obstacle  to  its  occurrence. 
It  should  be  added  that  the  facial  integuments  are 
sufficiently  held  up  for  the  deformity  to  be  perfectly 
corrected.  The  horizontal  part  of  the  apparatus 
allows  mastication  and  pronunciation  to  be  started 
afresh  without  delay."* 

Fixation. — The  apparatus  is  fixed  in  its  cavity 
with  the  help  of  springs;  or  to  these  may  be  added 
rings  adjusted  to  the  remaining  teeth-  If  such 
means  be  inadequate,  we  may  have  recourse  to  spikes 
buried  in  neighbouring  portions  of  bone. 

*  CI.  ^lartin,  Cong,  de  Madrid,  1903,  p.  96. 


1 82  INJURIES  OF  THE  FACE  AND  JAW 

III.  Construction  of  Appliances. 

A.  Primary  Appliance. — As  in  the  case  of  the  lower 
jaw,  we  must  obtain  a  natural  maxilla  corresponding 
approximately  to  the  age  and  development  of  the 
subject.  We  take  the  mould  of  the  parts  to  be 
replaced,  but  also  take  the  impression  of  the  teeth 
of  the  lower  dental  arch  of  the  opposite  side.  The 
height  is  arrived  at  by  a  line  drawn  from  the  neck 
of  the  teeth  or  the  alveolar  margin  to  the  middle  of 
the  orbital  margin,  due  allowance  being  made  for 
soft  parts  by  subtraction. 

If  we  have  to  make  an  apparatus  to  replace  the 
two  upper  jaws,  w^e  make  from  moulds  the  whole 
anterior  mass  of  the  maxillae,  plus  a  part  of  the 
neighbouring  bones  [malars,  nasals — Tr.].  This  part 
of  the  apparatus  should  be  made  of  pure  hardened 
rubber,  but  should  not  exceed  i  mm.  or  i'5  mm. 
in  thickness,  except  where  it  covers  the  irrigation 
canals  (which  are  made  by  the  same  process  as  for 
the  lower  jaw).  The  canine  fossa  should  be  more 
shallow  than  normal,  so  as  to  give  the  apparatus  a 
slightly  greater  bulk. 

Hinges. — These  are  placed  on  the  wax  model  so 
as  to  take  exactly  the  place  which  they  will  occupy 
in  the  vulcanite.  They  are  kept  in  place  by  zinc 
wires,  so  as  not  to  become  displaced  during  the 
filling.  The  appliance  is  made  in  two  parts,  upper 
and  lower,  in  wax.  It  is  not  until  the  baking  is 
finished  that  the  upper  part  is  divided  into  two  parts 
by  a  vertical  saw-cut.  The  thickness  being  minimal, 
one  need  not  take  precautions  against  porosity. 


CONSTRUCTION  OF  APPLIANCES  183 

B.  Final  Appliance. — ^In  distinction  to  the  former 
(A  supra),  the  apphance  is  in  a  single  piece,  and  has 
a  posterior  wall;  its  cavity  is  entirely  filled  up.  All 
the  buccal  part,  except  the  velum,  is  of  hardened 
rubber.  All  the  remainder  (destined  to  fill  the 
cavity  left  by  the  bony  ablation)  is  of  soft  rubber 
The  aim  of  this  is  not  to  irritate  the  deep  parts, 
although  obliterating  the  chasm;  if  this  point  be 
neglected,  the  patient  will  have  a  nasal  and  defective 
pronunciation.  After  the  final  appliance,  which  fills 
all  the  cavities  flush,  has  been  placed,  pronunciation 
becomes  normal. 

In  order  to  reduce  its  weight,  we  make  this  ap- 
paratus entirely  hollow. 

If  the  resection,  involving  both  maxillae,  has 
destroyed  the  vomer,  we  make  an  artificial  one, 
with  a  space  each  side  of  it  to  imitate  as  closely  as 
may  be  the  arrangement  of  the  nasal  fossae. 

The  final  appliance  is  attached  to  the  teeth  near-by 
with  gold  plates  or  springs.  Cases  occur  in  which, 
owing  to  the  irregularities  of  the  cavity,  the  piece 
holds  steady  of  its  own  accord. 

Composite  Impression. — Supposing  the  mould  is 
unsatisfactory  on  account  of  the  depth  of  the  cavity. 
We  make  use,  for  choice,  of  Stent's  or  godiva.  Begin 
by  moulding  the  deepest  parts  and  letting  them  cool; 
take  this  segment  of  the  impression  out  and  trim  it, 
then  mark  it  with  a  few  points,  oil  it  to  prevent  ad- 
hesion, and  apply  another  layer  of  godiva.  Three 
or  four  superposed  partial  impressions  constitute 
the  complete  mould  of  the  hollow.  When  the  suc- 
cessive layers  have  arrived  at  the  edge  of  the  palate. 


i84 


INJURIES  OF  THE  FACE  AND  JAW 


we  take  an  impression  of  the  palatine  vault  with 
the  softest  godiva  obtainable,  so  as  not  to  soften  the 
other  impressions,  and  proceed  as  for  an  ordinary 
model.  We  can  just  as  well  even  use  plaster  for  the 
last  impression.  With  the  help  of  the  points  pre- 
viously made  as  landmarks,  we  withdraw  separately 
the  partial  impressions,  reconstitute  the  total  im- 
pression, and  cast  the  model  in  plaster. 


Fig.   io8. — Final  Appliance  for  Upper  Jaw. 


Pont,*  recognizing  the  difficulty  of  retaining  the 
partial  impressions  without  displacement,  has  quite 
lately  indicated  a  process  to  keep  them  in  place. 
"  After  moulding  the  buccal  cavity  in  blocks  of 
Stent's,  we  perforate  each  block  through  its  centre. 
We  try  to  make  this  hole  in  the  same  direction  for 
each  cylindrical  piece,  so  as  to  arrange  a  lumen 
through  the  blocks.     Thus  we  have  a  veritable  little 

*  Pont,  "  Process  to  facilitate  Impression-Taking  in  Sur- 
giciil  Prosthesis  "  {La  Province  dentaire,  191 3). 


COMPOSITE  IMPRESSION  185 

tunnel  in  the  mass  at  its  centre  of  gravity,  and 
directed  obliquely  from  above  downwards  and  from 
before  backwards.  Having  done  this,  and  before 
replacing  the  blocks  in  the  nasal  cavity,  we  introduce 
a  Belloc's  sound,  or,  if  it  be  preferred,  a  soft  rubber 
sound,  into  one  nostril,  and  pass  it  in  until  its  end 
is  clearly  visible  in  the  buccal  cavity. 

"  This  little  manoeuvre  is  all  the  easier  to  execute 
as  the  velo-palatine  fissure  is  larger;  we  introduce 
into  the  eyelet  at  the  end  of  the  sound  a  little  silken 
cord  or  a  string,  and  extract  the  sound.  We  have 
now  a  string  which  enters  by  the  mouth,  and,  passing 
by  the  nasal  cavity,  exits  by  the  nostril.  While  the 
patient  catches  hold  of  that  end  which  emerges  from 
the  nose,  the  operator  passes  the  other  end  into  the 
hole  made  in  the  blocks  of  Stent's.  These  are  then 
put  well  into  place;  and  when  the  last  occupies  its 
proper  position,  we  fix  to  the  end  of  the  string  a 
little  wooden  rod  which  forms  a  stop-catch,  and 
prevents  the  string  from  being  dragged  out,  when 
we  pull  on  it  by  the  nostrils." 

Base. — We  make  in  the  first  place  the  horizontal 
part  of  the  appliance  in  hardened  rubber,  rose  pink 
like  an  ordinary  denture.  This  part  is  equipped 
with  teeth.  "  On  its  upper  surface,  at  the  circum- 
ference of  the  orifice,  we  make  a  narrow  edge  (always 
of  hard  rubber)  with  a  height  of  5  mm.,  which  comes 
into  exact  contact  with  the  area  surrounding  the 
orifice,  and  can  be  welded  on  to  the  upper  part  of 
the  appliance.  The  lower  face  of  this  lower  piece, 
which  should  lie  on  the  tongue,  represents  the  palate 
and  the  alveolar  margin.     We  flask,  vulcanize,  and 


1 86  INJURIES  OF  THE  FACE  AND  JAW 

trim,  and  on  the  upper  unpolished  surface  we  tit  the 
superior  part  of  the  appUance  "  (Martin). 

Upper  Part. — This  should  fill  up  all  the  cavity  left 
by  ablation  of  the  maxilla.  It  is  very  thin,  and 
through  almost  its  whole  extent  is  of  soft  rubber. 
To  obtain  it,  we  cork  up  in  the  mould  all  the  points 
which  we  do  not  want  filled  up;  and  at  the  points 
corresponding  to  the  nasal  fossae  we  place  several 
thicknesses,  so  as  to  contrive  the  opening  necessary 
for  respiration.  Next  we  overlay  all  the  internal 
surfaces  with  a  sheet  of  wax  of  i'5  mm.  thickness. 
Thus  we  get  the  shape  of  the  whole  cavity.  We  then 
fit  it  on  to  the  margin  of  the  corresponding  palatine 
piece.  We  flask  it  and  cook  it  separately.  Care 
must  be  taken  that  it  keeps  its  shape.  One  must 
use  sifted  plaster,  very  fine,  to  get  a  smooth  surface, 
and  take  care  not  to  have  air-bubbles.  One  may 
also  cover  the  plaster  surfaces  with  tin-foil. 

The  filling  is  done  with  soft  rubber.  Only  those 
parts  which  should  resist  cicatrization  will  be  of 
hard  rubber;  that  is  especially  the  anterior  and 
ant ero -lateral  surfaces.  However,  towards  its  lower 
edge,  at  the  level  where  it  joins  the  horizontal  part, 
it  is  goo(J  to  place  2  or  3  mm.  of  hard  rubber  to  make 
more  sure  of  the  union  of  the  two  parts  of  the  appli- 
ance, also  to  resist  losses  of  shape  which  may  occur 
at  this  point  (Martin). 

Vulcanization. — This  should  be  slow;  the  piece  is 
then  removed.  Guided  by  the  model,  we  fit  and 
weld  together  the  two  parts,  by  means  of  rubber 
slowly  dissolved  in  chloroform  and  spread  along  the 
borders  with  a  spatula.      With  a  drill  pierce  a  small 


PLACING  THE  PROVISIONAL  APPLIANCE       187 

hole  through  the  hard  rubber  into  the  hollow  of  the 
piece.  Fill  this  cavity  with  water,  then  close  the 
hole  with  a  rubber  peg.  The  piece  is  again  flasked 
and  heated. 

The  soft  rubber  which  enters  into  this  class  of 
appliance  should  always  be  pure  "  para  "  with  6  per 
cent,  of  sulphur;  it  should  be  vulcanized  for  four  or 
live  hours  at  145°  C.  One  can  later  hide  its  black 
colour  by  covering  it  with  a  thin  layer  of  rubber 
coloured  with  a  solution  of  red  or  rose.  Having 
cooled  the  piece  in  the  flask  and  removed  it,  we 
take  out  the  peg  and  pour  out  the  water.  The 
piece  has  kept  its  shape.  We  fill  up  the  hole  with 
rubber  or  a  screw.  If  the  piece  includes  any  springs, 
we  shall  have  selected  the  place  of  the  spring-holders 
for  this  hole.  The  soft  rubber  is  trimmed  with  a 
heated  spatula  which  is  applied  to  the  rough  points. 
We  clean  the  appliance  by  washing  it  with  chloro- 
form. 

CHAPTER  VH 

PLACING  THE  PROVISIONAL  APPLIANCE- 
TREATMENT— PLACING  THE  FINAL 
APPLIANCE 

To  negotiate  the  placing  of  the  provisional  appliance, 
the  prosthesist  should  equip  himself  with  the  following 
instruments:  A  dental  engine;  a  slip- joint  and  some 
drills;  some  files  for  rubber  and  for  metal;  a  saw- 
handle  and  some  saws;  a  screw-driver  and  some 
screws;  a  mallet  and  some  wedges;  some  bolts,  and 
a  spanner  for  nuts,  according  to  the  mode  of  fixation 


1 88  INJURIES  OF   THE  FACE  AND  JAW 

which  we  have  elected.  All  instruments  destined 
to  come  into  contact  with  the  wound  or  the  operator's 
hands  should  be  sterilized.  That  is  why  one  must 
possess  oneself  of  a  slip- joint,  which  can  be  sterilized, 
whereas  a  hand-drill  all  in  one  piece,  with  its  flexible 
arm,  can  at  best  be  made  questionably  sterile.  For 
the  same  reason  one  should  reject  any  instrument 
not  provided  with  a  metal  handle.  A  rubber  pros- 
thetic appliance  can  be  sterilized  by  boiling.  These 
preparations  being  effected,  the  intervention  will 
take  place  in  three  stages  which  are  sharply  distinct 
from  each  other,  and  during  which  the  surgeon  and 
prosthesist  alternately  help  each  other. 

First  Stage. — The  surgeon,  helped  by  the  pros- 
thesist, performs  the  resection  of  the  jaw  as  decided 
upon,  and  attends  to  haemostasis  of  the  wound. 

Second  Stage. — The  prosthesist,  helped  by  the 
surgeon,  tits  the  appliance  between  the  bony  frag- 
ments. By  means  of  saw  and  file  he  prunes  away 
the  excess  of  rubber  (which  he  has  had  the  foresight 
to  leave),  so  as  to  facilitate  its  adjustment.  He 
satisfies  himself  that  this  adjustment  is  exact,  by 
verifying  the  correct  interdental  articulation  of  the 
jaws  on  the  opposite  side.  Having  once  reduced  the 
appliance  to  suitable  proportions,  he  makes  holes  in 
the  bony  fragments  with  a  drill  and  a  dental  engine, 
or  tne  hand-drill  which  we  have  described  on  p.  242, 
Fig.  117.  If  he  uses  screws  or  wedges,  the  holes 
involve  only  the  outer  table  of  the  bone;  if  he  uses 
bolts,  the  jaw  will  be  perforated  through  and  through. 
Having  made  these  points  of  retention,  he  next 
proceeds  to  place  the  screws,  wedges,  or  bolts. 


A  FTER-TREA  TMEXT  189 

Third  Stage. — The  surgeon  finishes  the  operation 
by  suturing  the  soft  parts.  The  second  stage,  which 
belongs  to  the  dentist,  is  far  the  longest.  The 
adjustment  of  the  appliance,  and  especially  its  fixa- 
tion, are  always  fairly  difficult;  for  the  things  must 
be  placed  all  in  a  moment  with  speed  and  precision. 
The  prosthesist  must  always  arm  himself  with 
calmness  for  every  attempt,  and  with  a  large  stock 
of  patience  for  such  intervention. 

After-Treatment. — The  bony  fragments  solidly 
joined,  and  the  maxillary  arc  reconstituted,  the  skin 
incision  as  a  rule  unites  by  first  intention.  But 
sometimes  a  fistula  persists,  and  is  encouraged  by 
the  presence  of  the  appliance;  the  buccal  wound 
persists,  and  all  the  surgeon's  care  from  that  moment 
must  be  directed,  not  to  make  the  wound  fill  up, 
but  to  make  it  epithelialize  as  quickly  as  possible. 
More  or  less  suppuration  is  established.  There  is 
nothing  surprising  in  this,  since  it  occurs  in  a  wound 
communicating  with  a  septic  focus  in  the  mouth. 
We  should  make  every  effort  to  drain  this  anfractuous 
cavity  by  the  mouth,  to  prevent  the  pus  finding 
tortuous  paths  outwards  by  making  one  or  more 
cutaneous  fistulae.  So  as  to  obtain  this  drainage, 
constant  irrigations  must  be  made  in  the  depth  of 
the  mandibular  chasm  through  canals  which  per- 
meate the  prosthetic  appliance  in  every  direction. 
Thus  we  bring  to  bear  on  all  surfaces  weak  anti- 
septics intended  to  cleanse  them.  This  drainage 
should  be  made  continuous;  therefore  we  must 
multiply  the  irrigations,  and  carry  them  out  ah  out 
once  an  hour.     [The  italics  are  the  Translator's,  and 


I  go  INJUR  FES  OF   THE  FACE  AND  JAW 

signify  that  this  idea  is  strongly  supported  by  his 
personal  experience.]  If  we  do  not  practise  them 
regularly,  we  encounter  infective  phenomena  at  once. 

In  proportion  as  cicatrization  advances,  we  pro- 
gressively diminish  the  number  of  irrigations,  and 
when  the  former  is  complete  we  arrive  at  their  nearly 
complete  cessation.  This  cicatrization  is  very  long, 
because  the  wound  must  be  covered  with  an  epithelial 
clothing,  and  this  despite  the  unfavourable  con- 
ditions created  by  the  presence  of  a  septic  foreign 
body.  We  know  the  difficulties  encountered  by 
otologists  to  prevent  petromastoid  excavations  from 
filling  up,  and  to  obtain  a  good  epithelialization. 
This  takes  at  least  two,  often  three,  months  of 
methodical  dressings.  Maybe,  however,  we  can 
hasten  healing  by  borrowing  from  oto-rhinology 
some  of  their  methods  of  coaxing  epithelial  growth, 
notably  dressings  with  boric  acid  or  peroxide  of 
zinc,  slid  in  between  the  appliance  and  the  granu- 
lating surface  of  the  wound.  [No  such  method  as 
this  is  in  common  use  by  British  oto-rhinologists 
for  mastoid  cavities  or  for  nasal  operations — Tr.] 

The  primary  appliance  must  stay  in  situ  a  long 
time,  eight  months  at  least  (Martin),  which  facilitates 
the  application  of  the  final  appliance.  The  older 
the  scar,  the  less  its  tendency  to  retraction.  It  is 
better  to  mobilize  the  appliance  as  soon  as  possible 
after  the  first  few  weeks,  so  as  to  facilitate  lavage 
and  thereby  hasten  epidermization.  To  mobilize 
the  apparatus,  we  remove  the  screws  which  attach 
it  to  the  jaw,  and  plug  the  internal  canals  with  wax; 
but  it  is  not  until  a  long  while  afterwards  that  the 


CONCLUSIONS  191 

final  appliance  is  fitted.  The  substitution  of  the 
second  for  the  first  appliance  should  be  done  without 
delay.  If  not — if  we  leave  the  mouth  without  any 
appliance  for  some  days — the  final  appliance,  as  a 
result  of  the  cicatricial  contraction,  cannot  be  fitted 
and  must  sometimes  be  a  good  deal  modified.  The 
final  appliance  possesses  no  canals  for  irrigation, 
and  should  be  frequently  removed  for  cleansing.  But 
it  should  shortly  be  replaced,  so  that  there  should 
be  no  retraction.  For  this  same  reason  the  invalid 
wears  it  constantly,  and  does  not  remove  it  at  night. 


CHAPTER  VHI 

CONCLUSIONS 

Advantages  of  the  Method. — Thanks  to  prosthesis, 
one  can  easily  oppose  the  retraction  of  the  tongue 
by  passing  through  it  a  metal  wire  and  fixing  it  to 
the  artificial  jaw,  instead. of  attaching  it,  as  formerly, 
to  the  remaining  fragments  of  the  jaw,  to  skin,  or  to 
pieces  of  dressing.  These  latter  mentioned  methods 
do  not  render  it  very  firm,  and  do  not  place  the 
patient  out  of  danger  of  asphxyia. 

By  means  of  immediate  prosthesis  we  guide  cica- 
trization. The  appliance  resists  any  deformity  of 
soft  tissues  or  approximation  of  the  remaining  bony 
parts.  Since  its  bulk  and  shape  are  the  same  as 
those  of  the  jaw  removed,  the  result,  from  an  aesthetic 
point  of  view,  is  perfect.  The  patient  has  the  same 
cast  of  countenance  as  before  the  operation,  instead 


192  INJURIES  OF  THE  FACE  AND  JAW 

of  the  hideous  deformities  which  follow  resections 
of  tlie  lower  jaw  not  followed  by  immediate  pros- 
thesis. Swallowing  is  made  easy;  the  appliance 
gives  to  the  tongue  a  point  d'appid  sufficient  to  urge 
the  bolus  towards  the  pharynx.  By  means  of  this 
appliance,  mastication  of  semi-solid  food  is  possible 
a  few  days  after  operation,  and  little  by  little  solid 
food  follows  in  turn.  Fluids  can  be  taken  by  the 
patient  himself  quite  soon  after  the  operation;  the 
oesophageal  tube  is  not  called  for.  Speech  is  equally 
made  easier;  the  invalid  expresses  himself  almost 
perfectly  in  an  intelligible  way,  which  is  nowise 
comparable  to  the  incomprehensible  jabbering  which 
goes  with  jaw  resections  not  followed  by  prosthesis. 
Lastly,  thanks  to  the  reconstitution  of  the  natural 
dam  formed  by  the  lower  jaw  against  the  trickling 
of  saliva,  the  invalid,  at  the  end  of  two  or  three 
days,  retains  it,  and  is  not  still  further  exhausted  by 
endless  salivation.  These  functional  results  cannot 
fail  to  improve  with  time.  In  proportion  as  the 
appliance  settles  down  into  place,  it  renders  increasing 
service,  and  cannot  be  discarded  without  a  con- 
siderable upset  of  the  subject's  conditions  of  life. 

Disadvantages.  —  Boennecken  has  formulated 
against  Martin's  immediate  prosthesis  certain  ob- 
jections which  we  may  recapitulate  thus: 

1.  Martin's  appliance  is  a  crime  against  asepsis, 
for  it  constitutes  a  cause  of  infection. 

2.  Foreign  bodies  are  only  well  tolerated  if  they 
are  small.  Now;  Martin's  appliances  are  bulky  and 
give  rise  to  irritation  of  the  tissues. 

3.  Martin's   appliance   favours   the   recurrence    of 


DISADVANTAGES  193 

the  tumours  on  account  of  which  one  has  inter- 
vened. 

4.  The  apparatus  is  compHcated  and  difficult  to 
make. 

Of  these  criticisms  against  Martin's  method  a 
certain  number  may  be  thrown  aside.  The  size  of 
a  foreign  body  has  no  influence  on  its  tolerance  by 
the  tissues.  Experimental  researches  by  one  of  us* 
allow  us  to  deem  the  volume  to  be  a  negligible 
factor  in  its  tolerance.  Besides,  as  regards  Martin's 
system,  the  question  is  irrelevant,  since  the"  appliance 
replaces  a  bony  part  already  existing,  and  does  not 
create  anew  for  itself  a  place  in  the  midst  of  the 
tissues.  Nevertheless,  this  idea  seems  to  have 
met  with  the  approval  of  some  practitioners  who 
use  immediate  prosthesis  ;  for  they  seem  unani- 
mous in  seeking  to  reduce  the  volume  of  the  ap- 
pliances to  a  minimum,  and  to  replace  vulcanized 
rubber  by  metal.  The  contrivance  suggested  by 
Boennecken  is  a  metal  hoop,  keeping  the  two  frag- 
ments separated.  Verneuil  and  Michaels  had  already 
made  use  of  it.  Michaels'  invention  was  a  metal 
bridge  (iridium-plated  platinum)  formed  by  two 
wires,  placed  parallel  for  the  length  of  the  part 
resected.  Metal  rings  are  soldered  to,  and  so  con- 
nect, the  two  platinum  rods,  of  which  the  lower  is 
twice  as  strong  as  the  upper.  This  metal  bridge  is 
fixed  by  screws  to  the  fragments  of  the  natural  jaw. 
The  underlying  principle  of  this  combination  is  the 
easy   occlusion   of  the   divided  tissues   and  the  re- 

*  G.  Lemerle,  "  Contributions  to  the  Experimental  Study 
of  Internal  Prosthesis,"  These  Paris,  1907. 

13 


t94  INJURIES  OF   THE  FACE  AND  JAW 

establishment  of  the  soft  parts  across  the  rings  of 
the  apphance.  In  the  middle  of  the  appliance  is  a 
nut,  "  tapped  "  with  a  female  screw-thread;  into 
this  fits  a  male  screw,  2  cm.  long,  which  will  later  on 
give  a  purchase  for  the  fitting  of  an  artificial  denture. 
This  appliance  was  well  borne  for  seven  or  eight 
months ;  at  this  moment  a  recurrence  of  the  neoplasm 
discounted  its  permanent  success.''" 

Gillard  is  yet  another  who  has  used  a  metal  appli- 
ance consisting  of  a  rod  with  clasps  and  catches 
which  fit  tlie  bony  fragments ;  he  alters  the  dimensions 
of  his  appliance  at  the  time  of  placing  it  by  a  most 
simple  scale  of  measurement.  Lastly,  Partsch  of 
Breslau,t  so  as  to  keep  the  spread  of  the  bony  frag- 
ments without  hindering  the  recovery,  applies  to 
their  inner  surface  two  bands  of  aluminium  bronze, 
furnished  with  openings.  These  divergent  ideas  have 
brought  about  a  regrettable  confusion  between 
prosthetic  methods.  The  truth  is  that,  just  as  the 
method  invented  by  Martin  is  consistent  with  the 
end  at  which  he  aimed,  so  also  those  authors  who 
have  followed  him  have  worked  on  his  lines,  and  have 
made  prosthetic  attempts  which  are  strictly  speaking 
neither  immediate  nor  internal  prosthesis.  By  his 
immediate  method  Martin  seeks  to  prevent  a  wound 
from  filling  up,  and  to  make  it  skin  over;  so  that  he 
may  later  restore  the  loss  of  substance  by  means  of 
a  mobile  appliance  put  into  the  breach,  which  has 
become    covered    with    mucous    membrane    like    an 

*  Michaels,    Odontologie   et   Revue   internationale   d'odonlo- 
logie,  Mai,  1S94. 

f  Congres  de  la  Societe  allemande  de  chirurgie,  Avril,  1897. 


DISADVANTAGES  195 

alveolus.  In  fixing  metal  hoops  to  the  bony  ex- 
tremities, the  authors  just  quoted  have  abandoned 
immediate  prosthesis;  for  these  metal  arcs,  although 
holding  the  fragments  in  place,  no  longer  hinder  the 
wound  from  filling  up.  Such  metal  splints,  then, 
should  not  later  give  place  to  final  and  movable 
appliances,  as  in  Martin's  method.  They  are  placed 
to  stay  permanently;  thus  we  are  here  concerned 
with  internal  prosthesis,  not  immediate  provisional 
prosthesis.  These  attempts  at  internal  prosthesis 
applied  to  the  lower  jaw  are  destined  to*  inevitable 
failure,  being  made  immediately  after  resection,  and 
therefore  in  a  septic  area. 

The  first  rule  to  observe,  to  obtain  a  tolerance  to 
a  foreign  body,  is  rigid  asepsis.  This  is  not  obtained 
in  the  prosthetic  experiments  which  we  enumerated 
above.  Michaels,  for  instance,  passes  into  the  mouth 
a  metal  rod,  which  is  later  to  support  a  denture. 
This  rod  makes  a  communication  between  the 
maxillary  bed  and  the  septic  buccal  region;  infection 
is  inevitable,  intolerance  certain.  Martin's  method 
does  not  depend  on  the  principle  of  asepsis.  His 
immediate  apparatus  involves  a  longer  or  shorter 
suppuration,  and  can  cause  cutaneous  fistulae.  But 
these  drawbacks  are  fleeting,  since  the  immediate 
appliance  is  provisional,  and  all  these  happenings 
vanish  at  once  on  its  removal.  The  methods  of  im- 
mediate permanent  prosthesis  applied  after  resection 
of  the  mandible  are  in  just  the  same  way  a  crime 
against  asepsis.  They  entail  the  same  suppuration 
and  fistulae,  but  these  accidents  are  as  final  as  the 
appliance,   and  persist   until   the    latter   is  removed 


196  INJURIES  OF  THE  FACE  AND  JAW 

or  expelled  by  the  tissues.  In  any  infected  area, 
immediate  permanent  prosthesis  gives  failures;  only 
immediate  provisional  or  late  internal  prosthesis  can 
succeed.  Immediate  prosthesis  is  indicated  in  the 
event  of  a  resection  which  oversteps  the  horizontal 
part  of  the  jaw.  Late  internal  prosthesis,  on  the 
other  hand,  finds  its  application  after  partial  resec- 
tions of  the  horizontal  ramus;  for  it  is  impossible  to 
fix  firmly  an  internal  appliance  to  a  point  beyond 
the  angle  of  the  jaw. 

Boennecken  stigmatizes  Martin's  contrivances  as 
complicated  and  difficult  to  make;  but  this  objection 
carries  little  enough  weight,  if  the  results  obtained 
are  favourable.  More  serious  is  his  accusation  against 
this  method  that  it  encourages  recurrence  of  the 
neoplasms  for  which  the  operation  has  been  done. 
On  this  point  we  will  quote  the  words  of  Oilier:* 
"It  is  in  the  case  of  recent  or  old  traumatic  lesions, 
of  necrosis  of  the  jaws,  and  of  benign  growths,  that 
the  new  scheme  of  prosthesis  wiU  render  the  greatest 
help.  For  malignant  growths  it  is  otherwise,  notably 
in  cases  where  the  spread  of  the  lesions  has  not 
allowed  of  a  very  wide  extirpation  of  the  suspected 
tissues.  In  such  circumstances  any  local  irritation 
cannot  fail  to  encourage  the  neoplasms  of  which  a 
nidus  has  been  left  in  the  midst  of  the  tissues." 

]\Iany  writers  absolutely  reject  this  criticism, 
which    they    consider    unfounded. f     It    is    better, 

*  Oilier,  Preface,  p.  5,  "  Traite  de  Prothese  immediate," 
par  CI.  Martin,  Paris,  1S89;  chez  INIasson,  editeur. 

t  Martin,  "  Some  Remote  Results  of  Immediate  Prosthesis 
in  Resections  of  the  Mandible,"  These  Lyon,  1893. 


DISADVANTAGES  197 

perhaps,  to  take  up  an  agnostic  attitude  as  regards 
the  potential  influence  of  immediate  prosthesis  on 
the  recurrence  of  neoplasms.     In  a  general  way,  we 
believe  that   a  long  uninterrupted  irritation  might 
become    at    one    point    a    predisposing    local    cause 
of    incidence    of    epithelioma.     This    notion    is    old. 
Epithelioma   of   the   lip   or   tongue   was   christened 
"smoker's   cancer,"  by  which  it  was  inferred  that 
we  attributed   an   important   role   to   the   irritation 
engendered  by  tobacco  smoke  or  the  repeated  con- 
tact of  the  pipe-stem.     This  local  predisposing  cause 
has  to-day  taken  second  place,  and  there  is  a  tendency 
to  ascribe  much  less  importance  to  factors  of  local 
irritation  in  the  etiology  of  cancer.     Be  this  as  it 
may,  no  one  can  as  yet  state  that  a  suppuration  of 
prosthetic  origin,  prolonged  for  several  months,  plays 
no  part  in  the  recurrence  of  malignant  tumours  of 
the  jaws.     But  this  part,  if  it  exist,  should  probably 
be  appraised  as  small.     For  it  does  not  seem  that 
recurrences  are  much  more  frequent  after  jaw  re- 
sections for  epithelioma,  when  these  are  followed  by 
immediate  prosthesis,   than  when  this  method  has 
not   been   applied.     The   advantages   of   immediate 
prosthesis  cannot  be  denied;  they  are  insistent  in 
the  observations  of  Martin,   of  which  several  date 
back  ten  to  fifteen  years.*     In  particular,  we  should 
have  recourse  to  immediate  prosthesis  in  resections 
of  the  lower  jaw  extending  to  beyond  the  horizontal 
ramus;  in  such  cases  it  is  absolutely  indispensable, 

*  Amoedo,  "  Contribution  to  the  Study  of  Immediate 
Prosthesis  of  the  Jaws  "  (Cong.  dent,  internat.,  Paris,  1900, 
iv.,  p.  477). 


198  INJURIES  OF  THE  FACE  AND  JAW 

for  late  internal  prosthesis  is  inapplicable  at  the 
level  of  the  ascending  rami.  The  results  obtained 
fully  repay  the  trouble  and  the  difficulties  of  execu- 
tion.* "  Only,  let  us  warn  any  who  undertake  such  a 
piece  of  work  against  what  seems,  on  reading,  to  he 
its  simplicity.  In  the  course  of  its  execution,  one 
recognizes  that  this  operation — hy  which  we  do  not 
mean  only  the  placing  of  the  appliance — is  not  always 
as  simple  as  it  seems." '\  [The  italics  are  the  Trans- 
lator's.] 

*  CI.  ]\Iartin,  "  Some  Remote  Results  of  Immediate  Pros- 
thesis," 1S93. 

t  Maurice  Roy,  These  de  Paris. 


SECOND    PART 
INTERNAL    PROSTHESIS 

Internal  prosthesis  is  widely  divergent  from  the 
methods  of  late  or  of  immediate  provisional  pros- 
thesis. The  aim  of  these  latter  is  to  replace  losses 
of  tissue  (most  often  skeletal  parts)  by  apparatus 
remaining  in  communication  with  the  exterior. 
Conversely,  internal  prosthesis  buries  in  the  depth 
of  the  living  tissues  appliances  destined  to  stay  there 
permanently,  as  long  as  the  patient  lives.  In  a 
series  of  observations,  CI.  Martin  has  striven  to  get 
bony  regeneration  by  adopting,  as  guides  for  the 
periosteal  flaps,  metal  apparatus  which  he  left  in 
the  tissues.  To  his  method  CI.  Martin  has  given  the 
name  "  internal  prosthesis,"  in  contradistinction  to 
immediate  provisional  prosthesis;  the  latter  might 
be  called  "  external  prosthesis,"  because  in  these 
cases  the  appliance  retains  its  communication  with 
the  outer  world.  This  term,  "  internal  prosthesis," 
strikes  us  as  clear  and  precise,  so  we  shall  retain  it. 
But  we  shall  extend  its  meaning  to  embrace  all 
methods  of  which  the  object  is  to  replace  lost  s:b- 
stance  by  means  of  an  appliance  fixed  permanently 

199 


200  INJURIES  OF  THE  FACE  AND  JAW 

in  the  tissues,  and  destined  to  be  a  functional  sub- 
stitute for  an  indefinite  time. 

Internal  prosthesis  includes  two  methods: 

1.  Internal  prosthesis  as  a  guide  to  bony  regenera- 
tion. 

2.  Internal  prosthesis  replacing  missing  substance. 


SECTION    I 
INTERNAL   PROSTHESIS 

(Intended  to  guide  Bony  Regeneration,  whether  by 
Subperiosteal  Resection  or  Graft) 

An  appliance  is  permanently  abandoned  in  the 
tissues.  It  consists  of  a  metal  cage  fixed  to  the  ends 
of  two  bony  segments,  and  destined  to  contain  the 
fragments  of  periosteum-covered  bone,  and  to  serve 
as  guide  to  the  new  bone  arising  out  of  this  graft. 
This  process  we  owe  to  CI.  Martin,  who  has  published 
an  experimental  study  made  on  dogs.* 

Michaels  has  applied  to  man  an  enarthrodial  joint 
acting  as  a  prop  to  the  periosteum,  after  subperi- 
osteal resection. 

"  It  concerned  a  patient  aged  thirty,  who  had  a 
very  characteristic  history  of  infections.  In  May, 
1891,  he  came  into  Pean's  clinic  in  hospital  for  a 
cold  abscess  of  the  antero-superior  quarter  of  the 
arm.  In  June  an  incision  evacuated  pus.  He  had 
there  a  fistula.  His  scapula  movements  were  limited. 
In    February,    1893,    a    fistulous    track    was    found, 

*  CI.  Martin,  "  On  Bony  Regeneration  over  an  Internal 
Prosthetic  Appliance,"  Paris,  1899  (Institut.  internat.  de 
bibliogr.  scientif.). 

201 


202  INJURIES  OF  THE  FACE  AND  JAW 

down  to  the  humerus.  The  shoulder-joint  was 
globular,  and  the  articular  surfaces  sticky  with 
purulent  lymph.  Movement  was  impossible.  The 
patient  refused  disarticulation,  and  Pean,  having 
previously  agreed  with  Michaels,  reopened  on 
March  ii  the  previous  incision,  divided  the  soft 
parts,  and  came  upon  a  purulent  focus  which  he 
evacuated.  He  forthwith  disarticulated  at  the 
shoulder- joint,  and  resected  the  upper  quarter  of 
the  humerus,  taking  care  to  preserve  as  much  peri- 
osteum as  possible.  Then,  having  made  the  toilet 
of  the  wound,  Michaels  placed  his  prosthetic  appli- 
ance.    This  consisted  of  three  chief  pieces  : 

"  I.  A  straight  rod  8  cm.  long,  to  represent  the 
resected  part  of  the  humerus. 

"2.  Another  rod,  which  continued  the  first  to  a 
length  of  2  to  3  cm.,  replacing  the  neck. 

"  3.  An  irregular  sphere  of  3-5  cm.  diameter,  which 
made  up  the  humeral  head. 

"  The  first  piece  was  a  little  thinner  than  the 
humerus  which  it  replaced.  It  was  cut  transversely 
at  the  level  of  its  lower  end,  which  was  fixed  to  the 
remaining  part  of  the  humerus  by  four  short  pro- 
longations, in  pairs.  The  longer  pair  measured 
I "5  cm.,  the  two  others  7  mm.  They  were  each  of 
platinum-iridium,  1-5  mm.  thick.  They  were  free 
at  the  lower  ends,  where  they  formed  a  small  loop; 
whilst  at  the  upper  ends  they  were  approximated, 
and  soldered  to  a  metal  ring  which  was  immovably 
fixed  so  as  to  encircle  the  lower  part  of  the  prosthetic 
apparatus.  The  small  loop  formed  by  this  wire  was 
to  give  passage  to  a  platinum  screw  which  traversed 


INTERNAL  PROSTHESIS  203 

the  bone  through  and  through,  and  passed  across  the 
small  loop  of  the  prolongation  of  the  other  side,  and 
even  a  little  way  beyond  it.  So  we  were  able  to 
place  around  the  terminal  extremity,  which  was 
projecting,  a  little  bolt  which  enabled  us  to  couple 
very  intimately  the  external  surface  of  the  humerus 
and  the  internal  surface  of  the  two  prolongations 
opposed  to  it.  A  second  screw  and  bolt  fixed  in  the 
same  way  the  other  two  prolongations. 

"  At  the  upper  end  of  this  first  piece  a  second  was 
coupled,  which  expanded  slightly  in  the  transverse 
plane  from  below  upwards.  The  lower  part  of  this 
second  piece  was  cut  transversely,  like  that  of  the 
first,  whilst  its  upper  part  was  concave.  Moreover, 
this  piece  was  hollowed  at  its  centre  into  a  canal 
4  mm.  in  diameter,  in  which  a  screw  was  engaged; 
and  the  lower  end  of  the  screw  was  inserted  4  cm. 
into  the  rod  below.  Thus  the  lower  end  of  the  screw 
was  entirely  robbed  of  its  mobility,  whilst  its  upper 
part  allowed  the  second  piece  to  revolve  around  it, 
giving  an  almost  complete  circle  of  rotation.  And, 
as  the  screw-head  was  bigger  than  the  screw  itself^ 
the  lumen  of  the  piece  which  lodged  it  had  been 
enlarged  at  the  level  of  the  screw-head,  to  facilitate 
the  movements  of  rotation.  It  was,  in  fact,  the 
head  of  the  screw  which,  thanks  to  its  enlargement, 
prevented  the  two  rubber  rods  from  separating  from 
each  other  in  a  vertical  direction. 

"  The  upper  concave  part  of  the  small  rubber  rod 
was  intended  to  come  into  contact  with  the  third 
piece,  representing  the  humeral  head.  Meanwhile, 
instead  of  being  spherical,  this  piece  was  hollowed 


2  04  INJURIES  OF  THE  FACE  AND  JAW 

antero-posteriorly  for  i  cm.,  and  in  the  antero- 
external  direction  for  1*5  cm.  These  httle  canals 
lodged  platinum-iridium  wires  of  3  mm.  diameter, 
which  were  arranged  to  join  the  artificial  head, 
below  to  the  second  segment  of  the  appliance,  above 
to  the  scapula.  The  wire  which  encircled  the  head 
ensheathed  it  from  above  downwards,  following  the 
lateral  canal;  while  its  free  ends  descended  below 
the  head  with  a  gentle  bend,  and  fitted  tightly  with 
a  slight  eccentric  push  for  a  depth  of  3  cm.  into  two 
small  canals  made  specially  in  the  piece  below,  on 
either  side  of  the  screw-head.  From  this  arrange- 
ment it  resulted  that  the  head  was  sohdly  joined  to 
the  second  piece,  while  remaining  movable  on  it. 
It  was  an  easier  matter  to  fix  the  head  to  the  glenoid 
surface,  all  the  while  preserving  its  antero-posterior 
movements. 

"  For  this  purpose,  a  second  platinum-iridium 
loop  surrounded  the  antero-posterior  canal  (which 
was  deeper  than  the  other  by  0-5  cm.)  in  such  a  way 
as  to  pass  below  the  first  loop.  Whilst  the  middle 
of  this  new  loop  ensheathed  the  head,  its  free  ends 
pointed  to  the  glenoid  cavity.  There  one  of  these 
ends,  arranged  as  a  screw,  buried  itself  in  this  cavity 
and  in  the  scapular  neck  to  a  depth  of  3  cm.  It 
took  its  purchase  from  a  much  finer  platinum  wire, 
which  passed  on  alone  into  the  infraspinous  fossa, 
along  the  axillary  scapular  border. 

"  The  other  free  end  of  the  wire  curved,  left  the 
centre  of  the  glenoid  cavity,  and  encircled  the  neck 
to  divide  into  two  small  loops  which  embraced  the 
spine  of  the  scapula ;  one  lay  on  the  upper,  the  other 


INTERNAL  PROSTHESIS  205 

on  the  lower,  surface  of  the  spine  near  its  base. 
Thanks  to  this  arrangement,  the  artificial  head 
preserved  all  the  movements  of  the  normal  articula- 
tion in  relation  to  the  scapula.  It  must  be  added 
that,  to  facilitate  the  adherence  of  periosteum  and 
muscular  insertions  to  this  artificial  humerus,  I 
arranged  in  the  latter  some  small  ridges,  perforated 
here  and  there,  which  allowed  us,  by  means  of  catgut 
sutures,  to  suture  the  periosteum.  Similarly,  to 
fix  the  joint  capsule,  two  small  platinum  rings  were 
placed  on  the  outer  surface  of  the  head,  to  keep 
capsule  and  ligaments  in  their  normal  relations. 

"  In  the  construction  of  this  apparatus,  hardened 
rubber  and  platinum-iridium  are  the  only  materials 
which  should  be  used.  And  to  render  the  organic 
fluids  innocuous  to  the  rubber,  the  pieces  of  rubber 
are  boiled  for  twenty-four  hours  in  paraffin."  [This 
description  is  so  involved,  and  the  appliance  evidently 
so  complicated,  that  illustrations  would  seem  neces- 
sary in  order  to  understand  it — Tr.] 

It  has  been  possible  to  watch  the  remote  results 
of  this  attempt  at  internal  prosthesis  to  guide 
periosteum."^ 

Michaels  exhibited  at  the  1900  International  Dental 
Congress  a  certain  number  of  patients  on  whom 
surgical  or  prosthetic  intervention  had  been  essayed. 
Among  these  he  showed  the  subject  to  whom  had 
been  applied  the  enarthrodial  articulation  of  which 
we  have  spoken  above.  And  it  was  possible  to  prove 
that  the  apparatus  had  been  pretty  well  tolerated 

*  Michaels,   "  On  Prosthetic  Restoration  "    (Congres  den- 
taire  international  de  1900). 


2o6  INJURIES  OF   THE  FACE  AND  JAW 

by  the  tissues,  despite  a  fistula  persisting  at  the  site 
of  the  wound,  two  and  a  half  years  after  the  apparatus 
had  been  placed. 

"  In  July,  1895,  we  probed  this  fistula,  which 
satisfied  us  as  to  the  mobility  of  the  lower  segment 
of  the  apparatus.  The  skin  was  divided  in  such  a 
way  as  to  reach  the  apparatus,  and  we  cut  the  metal 
wires  which  fixed  it  to  the  original  humerus.  After 
energetic  pulling  we  removed  the  apparatus,  and 
curetted  the  fleshy  granulations.  Deep  to  these  we 
found  a  semilunar  piece  of  bone  of  new  formation. 
It  took  two  and  a  half  months  for  the  wound  to  heal. 
After  this  lapse  of  time — that  is,  five  years  after  the 
reopening  of  the  wound,  and  seven  years  after  the 
original  adaptation  of  the  apparatus — the  invalid 
made  good  use  of  his  arm,  which  had  kept  its  normal 
length.  The  shoulder- joint  could  perform  all  its 
movements  except  elevation.  The  patient  used  his 
right  just  as  well  as  his  left  arm,  and  daily  devoted 
himself  to  difficult  manual  labour  without  fatigue. 
From  the  skiagram  one  noted  that  on  its  posterior 
surface  the  bone  appeared  normal,  although  less 
smooth  on  its  other  side.  Thanks  to  radiography 
and  radioscopy,  no  one  could  contest  (i)  the  legiti- 
macy of  the  intervention,  or  (2)  the  results,  and  the 
help  given  by  the  surgical  prosthesis." 

Michaels  adds  the  following  general  indications 
for  apparatus  of  this  order: 

"  The  prosthetic  piece  should  be  a  replica  of  the 
bone,  or  of  that  fragment  of  bone  which  it  replaces. 
The  measurements  must  be  strictly  the  same.  The 
piece  must  fit  with  precision.     Apropos  of  this,  we 


INTERNAL  PROSTHESIS  207 

must  keep  a  watchful  eye  on  the  grip  which  the 
attachments  of  the  foreign  body  have  on  the  bone 
with  which  the  former  joins  to  comprise  the  complete 
limb ;  these  attachm'ents  should  grip  without  pressing 
too  hard,  so  as  to  avoid  mortification.  The  attach- 
ments must  be  filiform,  never  by  means  of  plates,  in 
that  all  that  part  of  a  bone  covered  by  a  plate  (and 
to  this  extent  deprived  of  periosteal  contact)  tends 
to  necrose.  Now,  the  area  of  bone  covered  by  a  wire 
is  negligible;  this  does  not  apply  to  the  area  covered 
by  a  plate,  which  is  the  greater  by  as  much  as  the 
plate  is  greater.  This  explains  why,  in  the  skia- 
grams which  I  have  the  honour  to  submit  to  you, 
my  platinum  attachments  take  the  form  of  a  cage. 
Lastly,  the  prosthetic  piece  is,  as  I  said  at  the  outset, 
only  a  guide  called  forth  to  direct  the  growth  of  new 
bone  which  the  periosteum  is  about  to  throw  out."* 
"We should  take  it  for  granted  that  v/e  shall  be 
able  to  remove  this  piece  on  the  day  when  the  newly 
formed  bone  is  firm  enough  to  allow  of  this.  And, 
with  this  idea,  we  must  not  enclose  the  prosthetic 
piece  with  the  periosteal  sheath,  but  rather  place  it 
as  if  it  were  a  wedge;  that  is  to  say,  we  leave  one 
aspect  of  the  prosthesis  uncovered  by  periosteum. 
The  result  is  that  the  appliance,  not  being  enclosed 
in  new  bone,  allows  the  latter  to  develop  freely,  and 
can  itself  be  lifted  out  at  the  right  moment.  That 
explains  on  the  one  hand  the  semilunar  form  affected 
by  the  new  bone,  on  the  other  hand  the  absence  of 
a  medullary  canal  on  radioscopy;  in  looking  at  the 
back  of  the  arm  the  bone  appears  normal.  Seen 
*  Michaels,  Congres  dentaire  de  1900, 


io8  INJURIES  OF  THE  FACE  AND  JAW 

from  the  other  side,  it  appears  to  us  not  quite  so 
smooth.  Thanks  to  the  combined  verdicts  of  radio- 
graphy and  radioscopy,  no  one  can  any  longer  doubt 
that  our  intervention  is  warrantable;  people  must 
admit  the  services  rendered  by  surgical  prosthesis." 

On  the  foundation  of  his  theories  Martin  has  shown 
some  patients,  which  has  allowed  him  to  establish 
that  his  appliances  were  well  borne,  and  that  at  the 
end  of  six  or  seven  years  his  patient  made  easy  use 
of  his  arm. 


SECTION    II 
INTERNAL  PROSTHESIS   PROPER 

(Replacing   Missing   Tissues,    and   Preserved   in   the 
Depths  of  the  Organism) 

As  far  as  the  skeleton  is  concerned,  the  prosthetic 
apphance  is  fated  to  accompHsh  in  their  entirety 
the  functions  of  the  portion  of  tissue  resected,  of 
which  it  win  take  the  place.  With  this  method  any 
bony  regeneration  is  discounted;  it  is  based  purely 
on  the  permanent  tolerance  which  the  organism  can 
offer  to  a  foreign  body  fixed  in  its  depths. 

It  presumes,  then,  the  possibility,  on  the  part  of 
the  tissues,  of  an  absolute  tolerance,  and  a  familiarity 
of  the  conditions  necessary  to  obtain  such  tolerance. 
It  must  be  insisted  on  that  as  yet  we  know  hardly 
anything  of  this  subject,  and  the  majority  of  the 
efforts  to  apply  this  method  have  been  followed  by 
failure.  CI.  Martin  himself,*  the  enterprising  pioneer 
of  immediate  provisional  prosthesis,  gives  it  but 
scant  praise.  We  think  it  fitting  to  quote  at  length 
the  exact  words  of  this  master  from  Lyons,  whose 
name  dominates  the  science  of  modern  prosthesis: 

*  Cl.   Martin,   "  On  Bony  Regeneration   over  an  Internal 
Prosthetic  Appliance,"  Paris,  1899. 

209  14 


2IO  INJURIES  OF  THE  FACE  AND  JAW 

"  I  made  the  first  trial  of  this  sort  of  prosthesis 
in  1878,  on  a  patient  from  Letievant's  clinic.  On 
this  man,  about  thirty  years  old,  I  fixed  a  false 
phalangeal  joint  to  the  little  finger  of  the  left  hand; 
and,  union  occurring  by  first  intention,  I  had  the 
satisfaction  of  seeing  the  invalid  leave  the  hospital 
with  a  platinum  joint  which  worked  admirably. 
The  result  remained  excellent  for  two  months,  and 
the  tissues  were  displaying  a  perfect  tolerance  vis-d- 
vis  with  a  foreign  body.  Unfortunately,  this  man, 
who  was  a  labourer,  often  undertook  muscular  work; 
and  one  day,  in  lifting  a  heavy  load,  his  joint  came 
apart  and  made  its  appearance  partly  outside  the 
skin. 

"  Later,  in  a  resection  of  the  mandible  made  by 
Professor  Polosson,  I  tried  to  leave  as  a  permanency 
a  bulky  prosthesis  of  hardened  rubber.  The  patient 
kept  it  eighteen  months,  but,  despite  anything  I 
could  do,  a  fistula  persisted,  which  compelled  me 
to  remove  it.  Other  efforts  of  the  same  sort  have 
since  been  made  by  Gliick,  who  announced  his 
observations  at  the  Berlin  Congress';  then  by  Pean 
in  1894.  But  these  results  showed  that,  if  the 
application  of  this  method  has  amounted  on  the 
whole  to  a  noteworthy  advance,  the  method  is  none 
the  less  far  from  perfect.  As  a  rule,  in  fact,  these 
pieces  are  badly  tolerated  by  the  tissues;  fistulae  are 
obstinate;  the  appliances  get  out  of  position,  and 
must  be  removed  if  they  are  not  spontaneously 
thrown  out. 

*'  It  is,  then,  patent  that  the  prosthetic  appliances, 
bulky  and  clumsy,  employed  up  to  date,  can  play 


INTERNAL  PROSTHESIS  PROPER  211 

their  part  of  skeletal  substitution  for  only  a  limited 
time.  And,  more  than  this,  that  they  are  never 
absolutely  tolerated  by  the  tissues,  in  which 
fistulae  always  persist.  I  do  not  think  that,  with 
this  type  of  appliance,  we  shall  be  able  to  arrive  at 
results  noticeably  better  than  those  which  have  been 
published  of  late  years.  These  pieces  are  too  massive, 
too  large,  to  be  well  borne,  and  they  fulfil  very  poorly 
the  role  of  skeletal  organ  which  had  been  expected 
of  them." 

However,  already  in  1893,  Weinlechner  and  Eisel- 
berg  restored  cranial  dehiscences  by  means  of  cellu- 
loid plates.  In  four  cases  infection  caused  two 
failures,  but  they  publish  two  cures.* 

In  1904  Hermann  applied  an  internal  prosthesis 
for  loss  of  cranial  substance;  he  publishes  one  success. f 
In  reality  he  had  a  failure  as  regards  prosthesis,  since 
suppuration  compelled  him  to  take  out  the  aluminium 
plate  which  he  had  placed. 

In  1903  Sebileau  and  Delair  applied  a  facial  internal 
prosthesis  after  total  resection  of  the  anterior  wall 
of  the  frontal  sinus.  They  obtained  a  success  which 
is  maintained  to  this  day.  In  1904,  for  a  gap  in  the 
skull,  they  fixed  a  metal  plate  on  the  same  plan  as 

*  Weinlechner,  "  Restoration  of  Losses  of  Skull  by  Means 
of  Celluloid  Plates  "  (i  case  of  cure). — Eiselberg,  ibid.  (3  cases, 
2  unsuccessful  owing  to  infection).  Soc.  Imperio-Royale  de 
Vienne  {Deutsche  medicinal.  Zeitung,  Mars,  1893;  Odontologie, 
Avril,  1893). 

f  Hermann,  "  Fracture  of  Skull:  Separation  of  Frontal. 
Sagittal,  and  Coronal  Sutures;  Trephining;  Metal  Prosthesis; 
Recovery  "  [Annates  de  la  Soc.  beige  de  chir.,  et  Annales  de  la 
Soc.  med.  d^Anvers,  Oct. -Dec,  1904,  p.  120). 


212  INJURIES  OF  THE  FACE  AND  JAW 

internal  prosthesis.     They  obtained  a  fresh  success, 
which  has  lasted  satisfactorily  up  till  now.* 

In  1907  Delorme  and  Delair,  in  a  case  of  a  large 
bony  loss  in  the  temporal  region,  succeeded  similarly 
with  an  internal  prosthesis.! 

More  recently  Sebileau  and  G.  Lemerle  successfully 
repaired  a  large  parietal  gap  with  a  metal  plate ;  • 
the  metal  chosen  in  this  case  was  silver,  for  reasons 
which  we  shall  see  later.  The  employment  of  paraffin 
injections  as  a  prosthetic  aid  has  consolidated  the 
hopes  which  we  justifiably  found  on  internal  pros- 
thesis, and  enables  us  to  classify  this  method  into 
two  system.s,  of  which  the  technique  is  quite  different : 

1.  Internal  prosthesis  by  appliances. 

2.  Internal  prosthesis  by  plastic  materials  injected 
into  the  tissues  or  pressed  into  normal  or  pathological 
bony  cavities. 

To  differentiate  these  two  systems  we  will  call  the 
latter  "  plastic  prosthesis."  Paraffin  has  now  become 
the  only  plastic  prosthesis  in  common  use.  The  use 
of  other  plastic  materials  and  appliances  is  still  but 
little  known,  and  one  may  say  that  internal  prosthesis 
is  still  in  its  infancy. 

To  succeed  by  this  attractive  method  implies  the 
possibility  of  indefinite  tolerance  of  the  tissues  to  a 
foreign  body.  The  tolerance  and  reactions  of  each 
particular    tissue    (periosteum,    bone,    neighbouring 

*  Sebileau,  "  Metallic  Facial  Prosthesis  after  Total  Re- 
section of  the  Anterior  Wall  of  the  Frontal  Sinus  "  [Revue  de 
stomatologie,  11  Nov.,  1903,  p.  514). 

f  Delair,  "  A  Case  of  Cranial  Prosthesis  "  (Soc.  d'odontol., 
Nov.,  1907)- 


REACTIONS  OF   PERIOSTEUM  AND  BONE       213 

structures),  the  nature,  shape,  mode  of  fixation,  and 
size,  of  the  foreign  body — all  these  are  just  so  many 
questions  to  which  we  must  have  a  clear-cut  answer 
before  we  dogmatize  as  to  the  practical  value  of  this 
kind  of  prosthesis.  [Moreover,  plastic  prosthesis  has 
the  grave  and  well-known  disadvantage  that,  if  the 
substance  is  ill-tolerated  or  changes  its  shape,  it  is 
impossible  to  remove  it  completely. — 'Tr.] 

As  we  said  just  now,  we  know  next  to  nothing  of 
this  subject;  the  laws  which  should  govern  internal 
prosthesis  are  not  yet  precisely  defined.  None  the 
less,  some  of  the  conditions  necessary  to  obtain  a 
tolerance  of  the  tissues  towards  foreign  bodies  already 
begin  to  crystallize  out.  One  of  us  has  attempted 
an  experimental  study.*  In  a  handbook  we  cannot 
dilate  at  length  on  a  question  which  is  still  most 
controversial.  Meanwhile  we  are  setting  ourselves 
to  expound  briefly  some  of  the  general  laws  which 
seem  to  govern  internal  prosthesis.  We  shall  now 
enter  upon  the  study  of  the  application  of  this 
method. 

CHAPTER  I 

TOLERANCE   OF   THE   TISSUES   TOWARDS 
FOREIGN  BODIES 

I.  Reactions  of  Periosteum  and  Bone  in  the  Presence 
of  Foreign  Bodies. 

Nicolas  described  periosteum  as  follows:  "Afibro- 
elastic  membrane,  rich  in  cellular  elements,  vessels, 

*  Georges  Lemerle,  "  Contribution  to  the  Experimental 
Study  of  Internal  Prosthesis,"   These  de  Paris,  1907. 


214  INJURIES  OF  THE  FACE  AND  JAW 

and  nerves,  which  invests  the  whole  surface  of  the 
bones  except  the  parts  covered  with  cartilage.  This 
membrane  plays  a  paramount  role  in  development; 
by  the  vessels  which  it  encloses  (nearly  ah  of 
them  destined  for  the  bone)  it  assures  the  bone's 
nutrition."* 

Theoretically  one  might  deduce  that  any  part  of 
the  bone  robbed  of  its  periosteum  for  the  fitting 
of  a  prosthetic  appliance  becomes  necrosed.  One 
might  equally  conclude  that  an  appliance  placed 
deep  to  the  periosteum,  and  exercising  on  it  a  certain 
amount  of  pressure,  will  entail  atrophy  thereof,  and, 
as  regards  the  vitality  of  the  subjacent  bone,  such 
consequences  as  are  the  logical  outcome.  Practically 
this  is  not  the  case.  Metal  plates  placed  beneath 
the  periosteum,  and  sutured  through  and  deep  to 
this  membrane,  after  a  stay  of  a  year,  have  not 
caused  any  functional  or  trophic  disabilities  in  the 
periosteum  or  the  bone  of  the  animals  experimented 
upon.  To  obtain  fixation  of  a  foreign  body  in  bone, 
the  best  tissue  reaction  for  which  the  prosthesist  can 
hope  is  osteitis  which  is  of  the  condensing  or  hyper- 
plastic type  from  the  beginning.  The  chief  cause  of 
failure  to  be  feared  is  a  rarefying  osteitis  where  the 
retention  appliances  are  fixed  to  the  bone.  Even 
if  it  may  sometimes  occur  that  a  happy  phase  of 
condensing  osteitis  follows  an  early  rarefying  osteitis, 
one  sees  much  more  often  that  the  latter  involves 
the  displacement  and  elimination  of  the  prosthetic 
appliance.       In    the    presence    of    a    foreign    body 

*  P.  Poirier,  "  Treatise  of  Human  Anatomy  ":  "  Structure 
of  Bone/'  by  A.  Nicolas,  p.  loi. 


REACTIONS  OF  PERIOSTEUM  AND  BONE        215 

rarefying    osteitis   may  be   due   to   three   principal 
causes : 

{a)  The  most  important  is  infection;  an  infected 
foreign  body,  fixed  in  the  bone,  will  always  involve 
rarefying  osteitis,  and  will  as  a  rule  be  eliminated 
with  some  sequestra. 

(&)  In  all  cases  where  the  bone  is  not  cleanly  cut, 
or  where  it  is  shredded  and  crushed  (as  in  a  badly 
performed  trephining  for  the  placing  of  a  prosthesis), 
the  damaged  zone  is  absorbed  aseptically,  and  ceases 
to  lend  support  to  the  apparatus  fixed  there. 

(c)  When  the  foreign  body  fixed  to  the  bone  is 
not  rigorously  immobilized,  it  soon  entails  a  zone  of 
rarefying  osteitis  round  about  its  retention-points, 
which  also  are  eliminated  at  the  same  time. 

On  this  subject  Martin's  experiences  are  very 
conclusive.  He  studied  bony  regeneration  on  the 
dog,  in  the  presence  of  an  internal  prosthesis,  and 
found  many  of  his  appliances  a  good  deal  displaced, 
owing  to  defective  immobilization.  Some  of  the 
facts  which  we  have  just  shown  enable  us  to  draw 
the  following  practical  conclusions: 

I.  Periosteum  offers  an  unlimited  tolerance  to 
foreign  bodies;  there  is  no  fear  of  producing  points  of 
bony  necrosis  by  the  application  of  prosthetic  appli- 
ances. From  a  practical  standpoint,  it  is  quite 
useless  to  strip  a  bone  of  its  periosteum,  at  the  level 
of  its  contact-points  with  the  appliance,  at  the  time 
of  fitting  the  latter;  not  that  such  denudation  would 
be  risky  if  of  only  limited  extent,  but  because  it  is 
so  much  time  lost  during  a  procedure  which  is  already 
quite  lengthy. 


2i6  INJURIES  OF   THE  FACE  AND  JAW 

2.  Bone  tolerates  quite  well  a  foreign  body,  as  long 
as  it  is  aseptic,  absolutely  immobile,  and  fixed  by 
some  means  to  cleanly  cut  uncrushed  surfaces  of 
bone.  In  trephining  we  should  therefore  use  very 
sharp  drills. 

It  is  on  these  conditions  that  we  shall  get  an 
osteitis  which  is  from  its  inception  of  the  condensing 
or  hyperplastic  type,  to  which  is  subordinated  the 
perfect  fixation  of  an  appliance  of  internal  prosthesis 

II.  Reactions  of  the  Tissues  according  to  the  Nature 
of  the  Foreign  Bodies. 

{a)  Vulcanized  Rubber. — The  rubber  ordinarily 
used  for  making  appliances  is  brown.  It  is  used  in 
preference  to  other  coloured  rubbers  (usually  em- 
ployed for  making  dentures)  because,  as  regards  its 
purity,  it  is  considered  to  be  unaffected  by  organic 
fluids.  This  is  a  fact;  but  other  rubbers,  coloured 
(by  vermilion  and  zinc  oxide)  red,  pink,  and  white, 
are  no  less  resistant.  If  all  the  rubbers  in  common 
use  for  dental  prosthesis  do  not  possess  the  mechanical 
qualities  of  black  rubber,  they  are  at  all  events 
perfectly  tolerated,  and  unaltered  in  a  chemical 
sense,  by  the  tissues. 

[b)  Metals. — Except  platinum,  gold,  tin,  and  alu- 
minium, metals  change  when  in  contact  with  the 
body  fluids.  But  the  changes  are  very  gradual, 
and  the  various  salts  thus  formed  have  no  apparent 
influence  on  the  vitality  of  the  tissues.  Iron  and 
copper,  for  example,  are  very  well  borne;  aU  the 
metals    commonly    used    for    dental    prostheses    are 


REACTIONS  OF  THE  TISSUES  217 

easily  tolerated.  Some  remain  unchanged,  others 
oxidize  here  and  there,  but  always  very  superficially 
and  with  no  sort  of  loss  of  tolerance. 

Maybe  these  oxidations  are  even  favourable  in 
certain  cases.  Silver  deserves,  in  this  connection, 
speci-al  attention.  We  know  already,  from  the  recent 
work  done  on  the  use  of  silver  salts  in  therapeutics, 
how  well  this  metal  is  borne  by  the  organism.  The 
researches  carried  out  on  coUargol  are  a  further 
proof  of  this.  The  use  of  silver  in  constructing 
apparatus  for  internal  prosthesis  presents  a  particular 
interest.  In  fact,  if  all  the  metals  of  which  we  have 
spoken,  and  also  all  the  vulcanized  rubbers,  are  well 
tolerated,  silver  seems  to  enjoy  something  beyond 
a  mere  tolerance.  It  becomes,  if  one  may  so  express 
it,  the  object  of  a  sort  of  adoption  by  the  tissue  in 
whose  depth  it  is  fixed.  Cellular  tissue  envelops  on 
all  sides  and  penetrates  the  smallest  crannies  of  a 
silver  plate;  if  the  latter  is  pierced  by  holes,  cellular 
strands  pass  through  these.  If  a  silver  plate  has  stayed 
some  months  in  a  dog's  body,  it  is  established,  when 
one  dissects  the  region,  that  connective  tissue  en- 
wraps it  so  closely  that  it  seems  to  stick  to  the 
surface  of  the  metal.  Other  metals  and  vulcanized 
rubber,  though  equally  well  borne,  do  not  present 
this  remarkable  peculiarity.  The  connective  tissue 
envelops  it  less  closely;  and  if  there  is  a  plate  pierced 
by  holes,  it  never  passes  through  them.  Silver  alone 
enjoys  this  privilege.*     These  qualities  of  extreme 

*  Billing  of  Stockholm  recommends,  for  the  same  reason, 
the  use  of  silver  for  making  internal  appliances.  Vide  J. 
Bilhng,  "  Von  der  Unterkiefer,  Resektions  Prothese,' 
Stockholm,  191 2;  Isaac  Marcus,  editeur. 


2i8  INJURIES  OF  THE  FACE  AND  JAW 

tolerance  seem  to  be  limited  to  this  connective  tissue, 
and  the  bone  reacts  no  differently  with  silver  than 
with  other  metals.  None  the  less  the  fact  has  a 
great  importance,  since  in  practice  the  tolerance  of 
a  prosthetic  piece  concerns  only  two  kinds  of  tissue, 
bone  and  connective  tissue.  As  a  fact,  a  foreign 
body  placed,  for  instance,  primarily  in  muscular 
tissue  is  found  later  at  the  same  spot,  but  encircled, 
somehow  encased,  by  connective  tissue.  This  later 
plays  a  protective  part  in  enveloping  any  apparatus 
placed  within  the  body,  so  thoroughly  that  we  can 
resolve  the  problem  of  tissue  tolerance  in  general 
towards  internal  prosthesis  into  the  simple  question 
of  tolerance  by  these  two  tissues — connective  and 
bony. 

III.  Tolerance  as  affected  by  the  Shape  of  the 
Foreign  Body. 

In  his  memoir  on  the  tolerance  of  foreign  bodies 
by  the  tissues,  Weiss  makes  the  statement  that 
irregular-shaped  bodies  with  sharp  projections  are 
not  so  well  borne  as  smooth  ones  with  rounded 
contours.  =•'  But  Weiss  was  studying  the  tolerance 
of  bodies  usually  septic.  If  there  is  a  difference  in 
the  tolerance  of  smooth  and  rugous  bodies,  this  is 
undoubtedly  because  the  latter,  in  the  event  of  their 
being  septic,  bring  with  them  into  the  tissues  more 
micro-organisms  than  bodies  with  smooth  surfaces. 
A  foreign  body  bristling  with  projections,  but  aseptic, 
is  perfectly  tolerated ;  for  the  connective  tissue  before 

*  Weiss,  "  On  Tissue  Tolerance  of  Foreign  Bodies,"  These 
d'agregat,  Paris,  iS8o. 


SHAPE  OF  THE  FOREIGN  BODY  219 

long  enfolds  it  and  protects  neighbouring  organs 
against  its  rugosities.  However,  we  do  see  intoler- 
ance, in  spite  of  asepsis,  in  certain  clearly  defined 
conditions : 

{a)  If  the  foreign  body  opposes  sharp  edges  to 
tissues  which  are  on  their  way  to  cicatricial  retraction, 
the  latter  get  cut  where  they  make  contact;  and  by 
this  mechanism  the  foreign  body  is  eliminated. 

A  good  example  of  this  type  of  intolerance  has 
been  published  by  Sebileau,''^  apropos  of  a  sufferer 
who  had  undergone  rhinoplasty,  the  new  nose  being 
fixed  on  to  a  metal  scaffolding  on  the  circumference 
of   the   nasal   skeleton.     This   scaffolding,    in   tripod 
form,  consisted  of  three  branches  whose  surfaces  of 
junction  were  not  rounded  off,  and  thus  presented 
fairly  sharp  edges.     Having  been  placed  under  good 
conditions   of   asepsis,    this   internal   prosthesis   was 
perfectly   tolerated   by   the   bony   tissue,    in   whose 
depths  it  had  been  implanted  and  firmly  retained. 
But  the  flap  which  covered  the  framework  under- 
went, during  scarring,  a  slow  retraction;  and  cutting 
itself  on  the  edges  of  the  metal  framework,  the  flap 
somehow  buried  itself  between  the  three  limbs  of 
the  tripod,  which  soon  began  to  make  its  way  to 
the  outside.     The  apparatus  had  to  be  removed,  and 
this   not   without   some   trouble,    for   it   was   solidly 
implanted  in  the  bone.     Thus,  the  intolerance  was 
not  due  to  bone,  neither  was  infection  to  be  blamed 
for  it;  but  it  depended  on  purely  mechanical  reasons, 

*  Sebileau,  "  ^Metallic  Nasal  Prosthesis:  Mechanism  of 
Elimination  of  the  Appliance  "  {Bull,  et  Mem.  Soc.  de  Chir. 
ds  Paris,  1903,  n.s..  xxiv.,  pp.  546-549). 


220  INJURIES  OF  THE  FACE  AND  JAW 

and  was  limited  to  the  soft  tissues.  This  is  a  note- 
worthy case  of  intolerance  due  to  the  shape  of  the 
foreign  body. 

{b)  If  a  foreign  body,  rough  with  irregularities,  is 
movable,  it  will  not  be  tolerated,  because  of  the 
mechanical  lesions  which  it  produces  all  around  it. 
But  let  the  same  body  be  immobilized  against  a 
bone  by  a  ligature,  and  the  connective  tissue  which 
shortly  encloses  it  in  its  meshes  protects  neighbouring 
organs  against  its  cutting  edges.  As  moss  will  not 
grow  on  a  rolling  stone,  so  connective  tissue  will  by 
no  means  envelop  a  movable  foreign  body.  If  the 
latter  offers  sharp  angles  and  cutting  borders,  it 
promotes  by  its  presence  a  brisk  reaction  which  in- 
volves its  rapid  elimination. 

IV.  Tolerance  depending  on  the  Mobility  of  the 
Foreign  Body. 

We  have  said,  apropos  of  foreign  bodies  garnished 
with  projections,  that  it  is  solely  their  mobility  which 
calls  forth  intolerance  on  the  part  of  the  tissues. 
We  can  extend  this  remark  to  all  foreign  bodies, 
whatever  their  shape. 

The  study  of  gunshot  wounds  gives  data  for 
interesting  observations  as  regards  the  tolerance  of 
bullets  by  the  tissues.  For  instance,  a  ball  having 
damaged  no  organ  of  importance,  and  not  having 
caused  any  suppuration,  is  abandoned  in  a  mass  of 
muscle.  This  foreign  body,  not  fixed  in  the  depth 
of  the  tissues,  travels  to  their  middle,  obeying  the 
various    factors    of   migration,    of    which   the    most 


MOBILITY  OF  THE  FOREIGN  BODY  221 

important  is  gravity.  After  a  varying  period  (it 
may  be  several  years),  the  ball  arrives  under  the 
skin,  and  always  ends  by  being  eliminated  in  a  region 
often  far  removed  from  the  initial  point  where  it 
was  arrested  in  the  tissues.*  The  only  cause  of  its 
elimination  lies  in  its  mobility.  Firmly  fixed  to  the 
skeleton,  it  w^ould  have  continued  to  be  tolerated 
indefinitely.  One  of  us  has  been  able  to  make  ex- 
perimental study  of  this  migration  of  foreign  bodies 
left,  mobile,  in  the  body-t 

Two  silver  plates,  enclosed  in  the  parietal  region  of 
a  dog,  were  retrieved  a  year  later,  one  from  the 
right  hypochondrium,  the  other  from  the  temporal 
fossa.  They  had  migrated  in  conformity  to  the 
inclined  planes  which  the  anatomical  arrangement 
of  the  part  offered  to  them.  Four  plates  of  various 
metals  placed  in  the  supraspinous  and  infraspinous 
scapular  fossae  of  a  dog  were  recovered  a  year  later 
near  the  shoulder-joint.  They  had  followed  the 
inclined  planes  presented  by  the  bony  surfaces. 
The  spine  of  the  scapula  being  directed  (in  the  dog) 
from  above  downwards  and  from  behind  forwards, 
foreign  bodies,  sliding  in  the  gutters  formed  by  this 
apophysis  with  the  scapula,  had  emigrated  in  the 
same  direction. 

It  seems,  then,  clear  that  movable  foreign  bodies 
roam  according  to  the  laws  of  gravity,  and  along  the 
inclined  planes  provided  for  them  by  the  anatomical 

*  Weiss,  "  On  Tissue  Tolerance  of  Foreign  Bodies,"  These 
d'agregat,  Paris,  1880, 

t  Georges  Lemerle,  "  Contribution  to  the  Experimental 
Study  of  Internal  Prosthesis,"  These  de  Pajris,  1907. 


2  22  INJURIES  OF   THE  FACE  AND  JAW 

arrangement  of  the  region  where  they  are  buried. 
To  this  (far  the  most  important)  passive  factor  in 
migration  we  should  probably  add  another,  active 
one — that  is,  the  movement  of  the  foreign  body 
initiated  by  the  contractions  of  the  muscles  in  pro- 
pinquity to  which  they  find  themselves.  In  a  supra- 
spinous fossa,  for  instance,  we  believe  that  a  foreign 
body,  free,  and  situated  between  bone  and  muscle, 
will  travel  along  the  inclined  plane  offered  by  the 
bony  framework,  passively  by  gravity,  and  actively 
under  the  influence  of  the  contractions  of  the  supra- 
spinatus.  It  is  likely  that  the  weight  of  the  foreign 
body  will  have  an  influence  on  the  rate  of  travel. 
If  a  body  fixed  in  the  skeleton  is  secondarily  mobilized, 
it  will  be  eliminated  by  the  bone  just  the  same  as 
if  it  had  been  freely  left  adrift  in  the  soft  parts. 
These  are  a  few  facts  of  paramount  practical  im- 
portance for  the  formulation  of  general  ideas  which 
should  regulate  the  construction  of  an  appliance  for 
internal  prosthesis,  and  the  choice  of  means  for  its 
retention. 


CHAPTER  II 

THE  VARIOUS  MODES  OF  RETENTION 

OF    INTERNAL    PROSTHESES,   AND    THEIR 

TOLERANCE  BY  BONY  TISSUE 

One  of  the  salient  causes  of  failure  often  encountered 
in  internal  prosthesis  is  the  mode  of  retention  chosen 
for  maintaining  the  appliance  in  situ.  These  re- 
tention methods  are  numerous  enough;  we  use,  in 


MODES  OF  RETENTTOX  223 

particular,  screws,  catches,  wedges,  bolts,  ligatures, 
and  hooks. 

I.  Screws. — This  is  the  means  of  retention  used 
most  often  by  CI.  Martin  for  fixing  his  appliances  of 
immediate  temporary  prosthesis.     It  has  given  him 
great  success;  nevertheless,  the  screw  does  not  fulfil 
all  the   conditions   which  we   postulated  just   now. 
In  fact,  if  we  trephine  and  then  put  a  screw  into  the 
bone,  the  screw-thread  applies  a  tearing  force  therein ; 
thus  we  create  the  zone  of  contusion  to  which  we 
referred  above,   and  the  absorption  of  this  zone  is 
a  potential  cause  of  elimination  of  the  screw.     None 
the  less,    apart   from   immediate   prosthesis,    screws 
have  yielded  good  results  in  the  treatment  of  certain 
fractures  by  making  certain  that  the  fragments  are 
kept  in  place.*     To  apply  them  in  operating  is  at  all 
times  much  easier  than  to  fix  bolts. 

2.  Catches. — The  catch  consists  essentially  of  a 
barbed  rod  buried  tightly  in  the  bone,  previously 
bored  by  a  trephine.  Theoretically  these  barbs  are 
destined  to  hold  the  metal  rod  in  the  bone. 

3.  The  Wedge. — This  system  of  retention  is  exe- 
cuted by  wedging,  into  a  hole  bored  into  the  bony 
table,  two  smooth  metal  rods,  which  are  buried  so 
as  to  fit  very  tightly.  These  metal  plugs  are  semi- 
circular in  section.  The  surface  touching  bone  is 
rounded,  and  that  by  which  each  glides  on  the  other 
is  plane.  They  are  usually  made  in  two  pieces; 
such  is  the  model  employed  by  Delair  (see  Fig.  no). 
We  find  it  more  handy  to  have  them  joined  at  their 

*  Lambotte,  "  Operative  Interference  in  Recent  and 
Old  Fractures,"  vol,  i.,  1906, 


224  INJURIES  OF  THE  FACE  AND  JAW 

ends.  One  can  easily  make  these  wedges  with 
pieces,  by  bending  a  piece  of  the  metal  wire,  called 
"  demi-jonc,"  into  the  shape  of  a  U,  with  its  branches 
very  close  together  (see  Fig.  112).  [Jonc  is  a  cane 
resembling  malacca;  in  section  it  is  circular.  Demi- 
jonc  therefore  means  "  half-round  " — i.e.,  one-half 
of  a  circle. — Tr.]  Whatever  type  of  wedge  we 
employ,  this  method  of  retention  is  excellent  for  the 
rapidity  of  its  application  and  the  perfect  tolerance 
shown  to  it;  for  it  never  injures  the  bone. 


Fig.  109. — Delair's  Bolt. 


B 


Fig.   iio. — Separate 
Wedges  of  Delair. 


^-^B>'S»1fe^m). 


Fig.   III. — Bolt  with  Large  Nut. 
(G.  Lemerle.) 


C 


D 


Fig.  112. — Wedge 
obtained  by  bend- 
ing a  Demi-jonc 
Wire  on  itself. 
(Lemerle.) 


4.  Ligatures  are  a  mediocre  method  of  fixation. 
They  have  the  merit  of  simplicity;  for  they  demand 
neither  preparatory  manoeuvres  nor  a  special  arma- 
mentarium of  instruments.  The  weakness  of  a 
ligature  is  its  lack  of  firmness.  It  is  liable  to  slip, 
to  become  displaced.  It  is  an  easy  and  well-borne 
method  of  fixation;  but  its  lack  of  precision  and 
solidity  renders  it  an  untrustworthy  method  which 


MODES  OF  RETENTIOX 


^^D 


should   be  only  exceptionally  employed  in  internal 
prosthesis. 

5.  The  Bolt  has  the  advantage  of  not  requiring  a 
thread  to  be  tapped  in  the  bone,  which,  being  un- 
hurt, tolerates  it  perfectly.     Taking  its  point  d'appiii 
from  the   opposed  bony  tables  which  it   traverses, 
the  bolt,  by  this  double  purchase,  offers  a  remarkable 
steadiness  coupled  with  an  extreme  precision.     Thus, 
it  resists  admirably  any  movement,  and  constitutes 
the  best  retention  arrangement  which  we  can  employ 
for  internal  prosthesis.     But,  to  make  good  use  of 
it,   it  should  conform  to  certain  conditions.     Thus, 
it  will  always  be  found  best  to  employ  two  incisions 
opposite  to  each  other,  so  as  to  place  conveniently 
a  bolt  through  a  diaph3'sis.     In  this  way  we  can  use 
a  bolt  with  a  fixed  head,  which  is  much  preferable 
from  the  standpoint  of  firmness.     In  fact,  it  is  the 
difficulty  encountered  in  placing  a  bolt,  when  only 
one  skin  incision  has  been  made,  which  has  led  the 
prosthesist  to  screw  on  the   two  nuts  after  he  has 
placed   the   bolt    in   position.     This   plan,    although 
rendering  feasible  the  use  of  a  single  incision,  still 
ofiers  various  difficulties,  for  to  twist  a  nut  in  the 
depths  with  a  bent  spanner,   without   seeing  it,   is 
always  slow  and  tedious.     The  fear  of  finding  that 
a  bolt  is  poorly  tolerated  by  neighbouring  tissues, 
owing  to  the  undue  projection  which  the  nuts  may 
make  on  the  surface  of  the  bone,  has  always  led  those 
who    have   written   on   this   subject    to    reduce   the 
thickness  of  the  nuts  to  a  minimum.     These  have 
finally  been  cut  out  of  a  very  thin  metallic  plate, 
so  as  to  require  onl}-  one  or  two  turns  of  the  screw. 

15 


226  INJURIES  OF  THE  FACE  AND  JAW 

Thus  the  grip  of  the  boh  becomes  a  good  deal  weak- 
ened, and  this  is,  according  to  our  way  of  thinking, 
robbing  this  method  of  one  of  its  sterhng  quahties. 
We  spoke  at  the  beginning  of  this  chapter  of  the 
tolerance  enjo^'ed  by  irregular  foreign  bodies,  if  only 
they  are  immovable. 

The  same  applies  to  nuts  which  make  a  projection 
on  the  bony  surface.  There  is,  then,  no  reason  to 
reduce  the  bulk  of  the  nuts.  We  considerably 
enfeeble  their  grip  thereby,  and  this  makes  them 
more  likely  to  become  movable.  For  this  loosening 
is  a  real  cause  of  intolerance,  whereas  the  influence 
of  shape  and  bulk  of  the  nuts  cannot  constitute  any 
cause.  Thus,  the  bolt  is  an  excellent  means  of  fixa- 
tion provided  that — (i)  there  is  enough  room  to 
place  it — that  is,  with  two  opposite  incisions  if 
necessary;  (2)  it  has,  whenever  possible,  its  head 
fixed  as  a  part  of  it;  (3)  it  has  nuts  of  sufficient 
thickness,  so  that  their  thread  can  have  a  grip  for 
an  adequate  length  of  the  bolt. 

6.  Hooks. — These  are  employed  above  all  in  bone 
surgery  to  maintain  the  fragments  after  certain 
fractures  (Dujarrier  and  Jacoel).  The  sole  defect 
of  this  method  lies  in  the  difficulty  which  may  occur 
in  boring  in  the  bone  two  points  exactly  correspond- 
ing to  the  ends  of  the  hook.* 

*  Vide  Potherat,  "  A  Case  of  Tolerance  by  Bone  of  Metallic 
Foreign  Bodies  "  (two  grafts  by  Jacoel  in  a  tibia  lasting 
eight  years,  uneventfully  and  without  mobilization)  {Gaz. 
med.  de  Paris,  11  Mars,  1914,  p.  74). 


PLASTIC  PROSTHESIS  227 

CHAPTER  III 

PLASTIC  PROSTHESIS 

Internal  prosthesis  includes,  as  we  have  said,  all  the 
artificial  restorations  which  are  finally  abandoned  in 
the  depth  of  living  tissues.  These  restorations  are 
brought  about,  now  by  various  appliances  fixed  to 
the  skeleton,  now  by  plastic  materials  enclosed  in 
the  body.  To  this  latter  method  we  give  the  name 
of  "  plastic  prosthesis,"  in  contradistinction  to  pros- 
thesis by  apparatus.  Paraffin  injections  have  given 
an  unexpected  scope  to  the  plastic  method.  These 
injections  now  constitute  a  prosthetic  intervention 
which  comes  into  the  domain  of  modern  practice  of 
numerous  specialists,  and  their  technique  has  been 
evolved  by  much  labour.  But  the  dentist's  province 
comprises  especially  prosthesis  by  apparatus:  the 
study  of  paraffin  injections  seems  to  us  not  to  come 
within  the  scope  of  this  manual.  Without  dilating 
at  length  on  paraffin  prosthesis,  it  occurs  to  us  in 
any  case  to  point  out  its  chief  fault. 

This  method  is  blind,  and  serious  accidents  have 
followed  the  eruption  of  the  paraffin  into  the  vessels 
of  the  region  involved.*  [The  sudden  and  permanent 
blindness  from  embolism  of  the  central  artery  of 
the  retina  has  occurred  at  least  sufficiently  often  for 
it  to  be  a  danger  to  be  reckoned  with;  and  the  risk 

*  Lee,  ]\Iaidment,  Hurd,  Ward,  and  A.  Holden,  "  Paraf&n 
Injection  followed  immediately  by  Blindness  from  Embo- 
lism of  the  Central  Artery  of  the  Retina  "  [Med.  Rec,  July  11, 
1903,  p.  53)- 


2  28  INJURIES  OF  THE  FACE  AND  JAW 

is  a  great  price  to  pay,  for  instance,  for  the  possible 
correction  of  a  saddleback  nose.  I  say  possible, 
because  the  method  is  not  even  technically  accurate; 
the  paraffin  may  spread  uncontrollably  beneath  the 
skin.  Lastly,  should  the  result  be  unsatisfactory, 
it  is  practically  impossible  to  remove  the  paraffin. 
-Tr.] 

Remote  trophic  disturbances  also  are  frequently 
observed  after  paraffin  injections.* 

Side  by  side  with  paraffin  injections,  which  affect 
the  cellular  tissue,  we  may  carry  out,  in  plastic 
prosthesis,  other  manoeuvres  whose  chief  aim  is 
skeletal  restoration.  This  is  what  various  writers, 
using  a  term  which  is  bad,  but  consecrated  by  custom, 
call  "  plumbing  "  the  bones.  These  restorations,  in 
contradistinction  to  paraffin  injections,  are  made 
through  open  incisions.  They  are  indicated  in  cases 
of  loss  of  bony  substance,  most  often  osteomyelitic 
in  origin.  In  the  neighbourhood  of  the  face,  there 
occur  cases  of  frontal  sinusitis  which  involve  bony 
lesions;  and  these  lesions  are  at  times  widespread 
enough  to  invite  the  surgeon  to  resect  the  whole 
anterior  wall  of  the  sinus  during  his  trephining. 
[Gouges  and  chisels,  not  trephines,  are  now  practically 
always  used  for  the  frontal  sinus. — Tr.]  After 
cicatrization,  the  loss  of  bone  induces  a  grave  facial 
deformity;  the  skin  is  strongly  retracted  down  to  the 

*  Dionis  du  Sejour,  "Trophic  and  Circulatory  Disturb- 
ances of  the  Skin  resulting  from  Paraffin  Injections  "  {Gaz. 
des  hop.,  19  Avril,  1904).  Morestin,  "  Accidents  caused  by 
Esthetic  Injections. of  Paraffin  "  (Soc.  de  chir.,  29  Janv., 
1908;  in  Presse  mSd.,  Fevr.,  1908,  p.  79). 


PRACTICAL  CONCLUSIONS  229 

level  of  the  gaping  sinus,  and  the  forehead  remains 
branded  with  a  deep  notch.  In  such  cases  the 
indication  is  to  strive  to  fill  up  the  supra-orbital 
chasm  by  means  of  a  plastic  substance. 

In  this  connection  various  authors  have  related 
their  attempts.  The  materials  employed  have  been 
the  most  diverse:  plaster,  iodoform,*  mastic  made 
of  calcined  bone,t  and  so  on.  The  results  have  some- 
times been  inconstant,  and  the  question  appears  far 
from  being  solved.  In  some  experiments  made  on 
dogs,  one  of  us  has  obtained  the  best  results  by 
using  an  amalgam  of  tin  and  silver,  such  as  is  used 
for  dental  stoppings.  We  consider  that  the  best 
substance  one  could  use  in  plastic  prosthesis  for  bony 
restorations  is  this  amalgam.  It  owes  its  chief  virtue 
to  its  ready  sterilizability,  which  can  be  carried  out 
without  any  anxiety  as  to  whether  the  boiling  will 
produce  any  change  in  it. 


CHAPTER  IV 
PRACTICAL  CONCLUSIONS 

The  conclusion  which  we  should  draw  from  these 
general  ideas  on  the  tolerance  of  foreign  bodies  by 
the  tissues  is,  first  and  foremost,  that  internal  pros- 
thesis is  feasible.  This  postulate  will  not  seem 
useless,  if  we  reflect  how  recent  this  method  is,  and 

*  Dreesmann,  "  Plumbing  Bones  "  {Beitrdge  ziir  klin. 
Chir.,  iv.,  3,  in  Semaine  mSd.,  Mars,  1893). 

t  Mosetig-Moorhof,  "  Plumbing  Bones  with  Iodoform  " 
{Centr.  Bl.  f.  Chir.,  iS  Avril,  1903), 


230  INJURIES  OF  THE  FACE  AND  JAW 

how  little  research  it  has  provoked  up  to  date.  All 
efforts  at  prosthesis  are,  then,  possible  and  legitimate, 
but  they  must  be  subordinated  above  all  to  a  rigorous 
asepsis.  Prosthetic  interventions  infringing  this  law 
are  doomed  to  failure.  That  is  why  an  open  internal 
prosthesis — that  is,  one  maintaining  communication 
with  the  air — is  an  impossibility;  for  the  direct 
result  of  such  an  arrangement  is  infection. 

It  is  neglect  of  asepsis  which  is  responsible  for  the 
majority  of  the  failures  met  with  in  internal  pros- 
thesis; these  mistakes  may  occur  in  the  placing  of 
the  appliance,  or  be  due  to  the  scheme  of  its  con- 
struction. A  distinguished  prosthesist,  describing 
some  years  ago  an  internal  prosthetic  contrivance 
for  use  after  resection  of  the  mandible,  expounded 
his  idea  as  follows:  A  metal  rod  was  fixed  to  the 
piece  which  replaces  the  piece  of  bone  resected,  and 
was  passed  through  the  buccal  mucosa  to  give  a 
basis  of  support  to  a  denture.  [One  would  have 
thought,  rather,  that  it  was  the  denture  which  sup- 
ported the  rod,  and  so,  indirectly,  the  prosthesis. 
— Tr.]  Thus  the  rod  made  an  internal  prosthesis 
communicate  with  the  septic  external  world.  Accord- 
ing to  our  view,  such  an  apparatus,  in  communication 
with  the  buccal  region,  is  destined  to  certain  elimina- 
tion due  to  unavoidable  infection.  Any  appliance 
of  internal  prosthesis  should  be  aseptically  buried  in 
the  tissues  and  entirely  cut  off  from  the  outer  world. 

Indications  for  Internal  Prosthesis. — Internal  pros- 
thesis may  be  immediate  or  late.  The  necessity  of 
always  placing  the  appliances  with  rigorous  asepsis 
almost    always   forbids    the    immediate   variety.     A 


INDICATIONS  FOR  INTERNAL  PROSTHESIS     231 

resection  of  the  mandible,  for  instance,  cannot  be 
absolutely  aseptic,  since  in  the  course  of  the  opera- 
tion saliva  bathes  the  operative  field.  An  attempt 
at  immediate  internal  prosthesis  would  be  followed 
by  a  certain  failure,  from  suppuration.  If,  on  the 
contrary,  we  wait  after  operating  until  cicatrization 
is  completed,  we  shall  be  able  during  a  second  opera- 
tion to  fix  an  appliance  of  late  internal  prosthesis. 

The  bony  ends  to  which  it  is  proposed  to  fix  a 
false  metal  skeletal  appliance  to  re-establish  the 
continuity  of  the  jaw  are  to  be  exposed  by  a  skin 
incision.  It  is  by  this  route  only,  and  by  sedulously 
avoiding  any  communication  with  the  septic  mouth 
area,  that  the  apparatus  should  be  inserted  ;  and  beneath 
it  the  tissues  are  sutured  in  successive  layers,  eschewing 
any  drainage. 

Thus,  internal  prosthesis  for  the  lower  jaw  can  only 
be  late,  so  as  to  remain  aseptic  and  to  preserve  its 
best  chance  of  success.  In  such  a  case  it  is  obviously 
indicated  to  prevent  cicatricial  contraction,  which 
would  tend,  after  the  resection,  to  carry  the  distal 
fragment  of  the  jaw  inwards  and  backwards.  For 
that  one  must  make  the  patient  wear,  soon  after 
the  first  operation,  a  contrivance  to  prevent  or 
correct  retraction.*  Internal  prosthesis  for  the 
lower  jaw  is  only  indicated  when  the  resection  has 
not  been  carried  higher  than  the  angle.     In  the  other 

*  Sebileau  and  G.  Lemerle,  "  Prophylactic  Appliance 
to  check  Cicatricial  Retraction  after  Partial  Resection  ot 
the  Mandible  "  (Soc.  de.  chir.,  Fevr.,  1907)- — G.  Lemerle, 
"  Appliance  to  reduce  Cicatricial  Retraction  after  Partial 
Resection  of  the  Mandible  "  {Le  Laboratoire,  Janv.,  1908). 


232  INJURIES  OF  THE  FACE  AND  JAW 

event  the  ascending  ramus  is  difficult  of  access,  and 
the  submaxillary  incision  gives  a  very  inadequate 


Fig.   113. — Delair's  Perforated  Plate  applied  to  the  Cranial 

Wall. 

exposure  for  fixing  bolts  to  the  piece.     Now,  this 
incision  should  be  kept  below  the  mandible,  and  not 


Fig.   114— Delair's   Extensible   Plate.     The   two   parts   are 

in  contact. 

prolonged  upwards,  lest  the  facial  nerve  be  involved; 
thus,  internal  prosthesis  for  the  mandible  must  be 
lunited  solely  to  restoration  of  the  horizontal  ramus. 


INDICATIONS  FOR  INTERNAL  PROSTHESIS     233 

The  upper  jaw  is  available  only  for  late  prosthesis, 
and  internal  prosthesis  may  be  said  to  have  no 
applicability  to  it. 

The  cranial  vault  is  the  most  propitious  region  for 
applying  internal  prosthesis  (Figs.  113,  114).  We 
are  concerned,  as  a  rule,  with  the  restoration  of  bony 
losses  consecutive  either  to  trauma  or  to  an  osteitis 
followed  by  large  sequestra,  or,  again,  to  surgical 
intervention — for  instance,  a  trephining  of  the  vault 
for  epilepsy.  There  again  the  prosthetic  applica- 
tion is  late.  It  is  almost  always  followed  by  the 
happiest  results,  for  the  metal  plate  fixed  to  the 
edges  of  the  bony  gap  can  be  introduced  with  an 
easy  and  perfect  asepsis,  and  later  on  is  not  exposed 
to  any  movement.  For  the  limbs,  screvvs  and  bolts 
are  used  more  and  more  for  bolting  the  fragments 
in  the  treatment  of  certain  fractures.  There  have 
been  no  real  attempts  at  internal  prosthesis  for  the 
limbs;  but  there  might  be  indications  and  good 
results.  Apparatus  for  immediate  provisional  pros- 
thesis, as  a  guide  for  periosteal  flaps,  placed  by 
Michaels,  show  to  what  length  we  may  hope  to 
extend  the  restoration  of  long  bones.  Internal 
prosthesis,  again,  is  indicated  in  certain  cases  of 
autoplasty,  as  a  help  to  hold  up  the  skin  flap,  and 
may  thus  render  great  service  in  finishing  a  rhino- 
plasty. Lastly,  Delbet*  has  quite  recently  used 
rubber  sheeting  as  internal  prosthesis.  In  one  case 
he  successfully  enclosed  a  thin  sheet  of  rubber  to 
isolate   the   extensor   tendon   of   the    first    phalanx, 

*  Delbet,  "  Rubber  Grafts"  (Ac.  Med.,  10  Mars,  1914; 
Presse  med.,  11  Mars,  1914,  p.  199). 


234  INJURIES  OF  THE  FACE  AND  JAW 

after  dissecting  up  its  adhesions  to  the  bone.  In 
another  case,  for  a  large  hernia,  he  remade  the 
indented  abdominal  wall  with  a  thin  leaf  of  rubber 
enclosed  in  the  tissues.  These  various  efforts, 
attended  with  success,  allow  us  to  look  forward  to 
a  constantly  increasing  number  of  applications  for 
internal  prosthesis  in  the  future. 


CHAPTER  V 
RHINOPLASTY  OVER  A  METAL  APPARATUS* 

I.  Generalities. 

Rhinoplasty  over  a  prosthetic  appliance  has  for 
its  object  the  remodelling  of  an  autoplastic  nose,  by 
providing  as  a  scaffolding  for  the  flaps  a  metallic 
internal  prosthesis  which  reproduces  the  nasal 
skeleton. 

Total  rhinoplasty  has  been  tried  for  a  long  time. 
We  get  the  flaps  from  the  forehead  (Indian  method) 
or  from  the  arm  (Italian  method).  The  results  are 
very  mediocre;  the  flap,  lacking  support,  sinks  down, 
and  the  operation  only  "  substitutes  a  ridiculous 
for  a  disgusting  infirmity."     Total  rhinoplasty  was 

*  We  place  this  chapter  in  the  part  of  this  manual 
devoted  to  internal  prosthesis.  Thereby  we  adhere  to 
custom.  But  we  consider  that  rhinoplasty  over  a  metal 
frame  communicating  with  the  exterior  does  not  constitute 
an  internal  prosthesis.  We  regard  it  as  something  between 
internal  and  external  prosthesis,  and  as  in  opposition  to 
all  that  we  know  regarding  the  tolerance  of  the  tissues 
towards  foreign  bodies. 


GENERALITIES  235 

accordingly  given  up,  only  artificial  noses  were  used, 
until  Letievant,  seconded  by  Martin,  exhibited  in 
1878  the  first  case  of  rhinoplasty  on  a  prosthetic 
appliance.*  MM.  Martin,  Ravanier,  de  Marion,  and 
Goldenstein,  have  since  treated  and  exhibited  many 
cases  of  this  sort  with  varying  results. 

The  metal  frameworks  are  borne  very  well,  causing 
no    suppuration    nor    pain;    they    re-establish    the 
respiratory    function,     very    difficult    without    this 
appliance.     The   nose   is   almost   normal.     One   can 
use  them  in  all  cases  of  loss  of  substance  of  the  organ, 
or  of  collapse  due  to  syphilis,  tuberculosis,  trauma, 
or   neoplasms,   even   malignant    (Martin).     The   flap 
to   cover  the   false   nasal   framework   can   be   taken 
either  from  the  soft  parts  of  the  nose  (if  any  still 
remain),  or  from  the  forehead,  or,  when  the  former 
have  quite  disappeared,   from  the  skin  of  the  arm 
(Italian  method). 

MM.  Ravanier  and  de  Marion  recommend  this 
latter  method.  In  fact,  the  lack  of  rigidity  in  the 
skin  of  the  arm,  which  caused  it  to  be  given  up  for 
rhinoplasty  by  surgeons,  loses  its  importance,  since 
the  flap  is  sustained  by  a  prosthetic  appliance. 
Moreover,  the  Italian  method  avoids  the  frontal  scar, 
also  any  sloughing  of  the  pedicle  by  torsion.  And 
it  gives  all  the  material  necessary  to  cut  out  a  big 
flap  and  give  a  generous  covering  to  the  metallic 
scaffolding.  [I  have  found  that  a  forehead  flap 
containing  a  previously  grafted  piece  of  rib  cartilage 
gives  the  best  result  for  total  rhinoplasty. — Tr.] 

*   Martin,     "  On    Immediate    Prosthesis,"    Paris,     1889; 
Masson,  edit. 


236  INJURIES  OF  THE  FACE  AND  JAW 

II.  Construction  of  the  Appliance. 

Martin,  after  trying  aluminium,  recommended 
platinum,  which  does  not  undergo  any  changes. 
Ribbons  of  platinum  are  used,  with  a  thickness  of 
0*4  to  0*5  mm.  and  a  width  of  5  to  6  mm.,  folded 


•■       1 

# 

> 

1              i 

• 

v^  ...     » 

.-•/•• 


Fig.    115. — ]vletal  Framework  for  the  Nose.      (Martin.) 

gutter -wise  and  soldered  to  form  a  cross,  in  such  a 
way  as  to  give  them  the  shape  of  a  normal  nose 
(Fig.  115). 

It  is  well  to  take  a  mould  of  the  face  so  as  to  make 
this  nose  of  normal  size,  and  harmonizing  well  with 
the  patient's  other  features.  We  solder  to  each  end 
some  platinum  points,  which  bury  themselves  in  the 
bone  to  a  depth  of  5  to  6  mm.,  and  thus  insure  the 
fixit}^  of  the  appliance. 


GOLDEN  ST  BIN'S  APPARATUS  i-^-j 

III.  Placing  the  Appliance. 

The  appliance  is  adjusted,  and  reduced  if  necessary, 
according  to  the  extent  of  the  resection  or  the  loss 
of  substance.  We  fix  it,  first,  to  the  upper  part  of 
the  nose,  by  piercing  holes  with  a  drill  in  the  thick- 
ness of  the  frontal  bone;  second,  to  the  base  of  each 
ascending  process  of  the  maxilla  in  the  same  way. 
We  smooth  down  the  flap  and  sew  it.  It  is  advised 
not  to  tighten  the  dressing,  many  cases  of  extensive 
sloughing  being  traceable  to  too  tight  bandages. 
We  explained  above,  apropos  of  tissue  tolerance 
towards  foreign  bodies,  the  mechanism  by  which 
internal  prostheses  are  extruded  in  certain  cases  of 
rhinoplasty.  If  the  appliance  has  too  sharp  edges, 
the  skin  involved  in  cicatricial  retraction  becomes 
cut  where  it  touches  them ;  so  that  the  metal  skeleton 
rapidly  comes  to  the  surface,  all  the  while  remaining 
perfectly  fixed  to  the  bony  circumference  of  the  nasal 
fossae.* 

IV.  Goldenstein's  Apparatus. 

Goldenstein,  so  as  to  facilitate  the  application  of 
the  appliance,  and  its  more  perfect  adaption  according 
to  the  indications  of  the  bony  substance  resected 
or  cast  off,  has  made  a  combined  apparatus  which 
is  movable  in  the  vertical  and  transverse  directions 
— that  is  to  say,  it  can  elongate  or  shorten,  and 
widen  or  narrow  down.  This  apparatus  consists  of 
two  parts : 

*  Sebileau,  "  ]Metallic  Nasal  Prosthesis:  Mechanism  by 
which  the  Apphance  is  eUminated  "  (Bull,  et  Mem.  Soc.  de 
Chir.  de  Paris,  1903,  n.s.,  xxiv.,  546-549). 


238 


INJURIES  OF  THE  FACE  AND  JAW 


1.  An  upper  segment  ending  above  in  a  small 
plate  fixed  to  the  forehead,  and  carrying  on  its,  lower 
aspect  two  rods. 

2.  A  lower  segment  which  holds  up  the  nasal  lobule, 
and  divides  into  two  lateral  branches.  At  the  back 
of  each  of  these  branches  are  two  rods,  fixed  at  one 
end,  but  compressible  at  the  other  like  a  pair  of 
pincers.     These   two   latter  rods   form   a   fork,   and 


Fig.   ii6. — -Nasal  Framework  perfected.      (Goldenstein.) 

grip  the  sharp  edges  of  the  ascending  (nasal)  process 
of  the  maxilla,  to  which  they  couple  the  lower 
segment. 

In  the  upper  part  of  the  lower  segment  two  sheaths 
receive  the  two  rods  of  the  upper  segment  and  join 
up  the  whole  contrivance  (Fig.  ii6). 

Thus  the  appliance  is  movable  in  a  vertical  direc- 
tion; and  also  in  a  horizontal  direction  by  its  posterior 
"  pincers,"  which  can  carry  it  to  right  or  left  as 
required. 


ELEVATION  OF  COLLAPSED   MOSES  239 

V.  The  Elevation  of  Collapsed  Noses. 

Related  to  rhinoplasty  on  a  prosthetic  appliance 
IS  the  elevation  of  collapsed  noses  by  a  metal  scaffold- 
ing and  without  surgical  operation. 

First  Case. — There  is  a  palatine  perforation.  The 
appliance  is  then  held  up  by  a  palatine  plate,  joined 
to  the  nasal  framework  by  a  pivot.  So  as  to  have 
the  exact  shape  of  the  nose,  one  can  push  out  the 
collapsed  organ  little  by  little  by  means  of  reinforcing 
pieces  of  godiva,  until  one  has  obtained  the  shape 
and  size  requisite  (Aeyrapaa).* 

Second  Case. — There  is  no  palatine  perforation. 
The  appliance  is,  then,  introduced  after  elevating 
the  fleshy  parts  of  the  nose  down  to  the  bones.  It 
is  fixed  by  means  of  points  in  the  bones,  or  by  using 
metal  forks  which  grip  the  sharp  margin  of  the  bones 
and  thus  assure  the  desired  fixity  (Martin). 


CHAPTER  VI 

CONSTRUCTION   AND    FITTING    OF   APPLIANCES 
FOR  INTERNAL  PROSTHESIS 

I.  Generalities. 

The  appliances  of  internal  prosthesis  must  as  far 
as  possible  be  made  of  metal,  preferably  silver. 
These  will  be  very  simple,  and  capable  of  being 
retouched  during  the  surgical  intervention.  If  we 
are  dealing  with  a  cranial  restoration,  we  make  a 

*  Sjoberg,  Congres  de  Nancy,  1896. 


2  40  IX JURIES  OF   THE  FACE  AND  JAW 

metal  plate  having  the  contour  of  the  gap  in  the 
bone,  but  a  little  larger;  for  although  it  is  always 
possible,  during  the  operation,  to  reduce  the  plate, 
it  is  quite  another  matter  if  we  wish  to  enlarge  it. 
The  plate,  of  a  sufficient  thickness  to  bear  the  pressure 
to  which  it  will  later  be  exposed,  will  be  slightly 
concave  to  facilitate  a  more  exact  adjustment.  The 
plate  is  pierced  by  holes,  to  make  it  lighter,  and  also 
to  allow  the  connective  tissue  (especially  if  we  are 
dealing  with  a  plate  of  silver)  to  penetrate,  and  so 
the  easier  to  adapt  itself  to  the  foreign  body  imposed 
on  it.  Wedges,  easily  obtained  by  bending  on  itself 
a  "  demi-jonc  "  wire,  constitute  the  means  of  reten- 
tion indicated  for  the  cranial  vault. 

If  we  have  to  deal  with  a  restoration  of  the  man- 
dible, the  appliance  will  consist  essentially  of  a 
simple  metal  splint,  resistant  enough  to  bear  the 
traction  forces  which,  will  play  on  it.  This  splint 
will  reproduce  the  curve  of  the  jaw,  and  will  be 
noticeabh'  longer  than  the  segment  which  it  is  to 
replace;  for  its  precise  adjustment  can  only  be  made 
during  the  operation.  For  the  lower  jaw,  bolts  are 
the  best  mode  of  retention.  These  have  nuts  of 
sufficient  thickness  to  take  a  good  purchase  on  the 
thread  of  the  bolt.  If  the  latter  has  a  movable 
nut  at  each  of  its  ends,  we  devise  a  curved  key  to  fit 
and  screw  up  the  nut  which  hes  against  the  deep 
surface  of  the  jaw. 

To  resume:  The  attempts  at  internal  prosthesis 
are  as  yet  too  few  for  it  to  be  possible  to  formulate 
precise  rules  defining  the  construction  of  the  appli- 
ances.    Their  scheme  must  be  altered  according  to 


INSTRUMENTATION  241 

the  cases  (always  widely  differing  from  each  other) 
with  which  we  are  confronted.  But,  speaking 
generally,  these  appHances  must  be  extremely  simple 
and  amenable  to  swift  and  easy  alteration  at  the 
moment  of  operation.  The  difficulty  of  internal 
prosthesis  lies,  not  in  the  construction  of  the  appliances 
in  the  laboratory,  hut  entirely  in  the  operating  theatrCy 
when  they  are  adapted  and  fixed  to  the  skehton. 


II.  Instrumentation. 

The  application  of  an  internal  appliance  neces- 
sitates various  manipulations,  and  often  numerous 
retouches;  so  that  the  prosthesist  must  needs  use, 
in  the  operating  theatre,  some  of  the  instruments 
ordinarily  used  in  his  laboratory.  Thus  it  behoves 
him  to  adapt  these  instruments  to  the  new  role 
which  they  have  to  fill.  They  will  have  to  be  always 
entirely  of  metal,  and  as  far  as  possible  plated,  so 
as  to  facilitate  their  cleansing  and  sterilization. 

These  instruments  not  being  on  the  market,  the 
prosthesist  will  himself  have  to  make  all  this  special 
outfit;  and  that  is  by  no  means  one  of  the  smallest 
difficulties  inherent  in  internal  prosthesis.  Thus, 
one  can  mount  some  files  (for  gold)  in  plated  handles, 
a  "  universal  holder  "  for  forceps,  some  flat  and  curved 
forceps,  straight  and  curved  scissors.  Generally 
speaking,  the  outfit  employed  for  working  on  gold 
tooth-crowns  finds  in  this  work  a  useful  application. 
To  these  add  a  small  mallet  fitted  on  to  a  metal 
handle.  For  piercing  the  holes  in  metal  plates  and 
for  trephining  bones,  we  make  use  c(  drills  and  burrs 
'    ^  16 


242  INJURIES  OF  THE  PACE  AND  JAW 

mounted  in  a  dental  machine.  In  such  cases  wc 
should  always  use  a  slip-joint.  This  instrument, 
being  detachable,  can  always  be  sterilized,  whereas 
to    a    hand-drill — not    detachable    from    the    flexible 


Fig.   117. — Hand-drill. 

arm — this  only  a,pplies  with  a  lot  of  trouble,  and  in 
a  way  which  is  not  above  suspicion.  But  the  dental 
drill  and  the  various  perforators  used  in  surgery  may 
be  readily  supplemented  by  drills  and  reamers 
mounted  on  large  metal  pear-shaped  handles.     On 


INSTRUMENTATION  243 

these  lines  M.  Delair  has  constructed  some  excellent 
instruments,  easy  to  handle,  by  means  of  which  it 
is  simple  to  trephine  the  bones  and  enlarge  the  holes 
(which  have  previously  been  nibbled  out  with  forceps) 
in  metallic  plates.  So  as  easily  to  get  these  instru- 
ments, one  may  with  advantage  use  handles  such 
as  are  fitted  to  "  root  screws."  That  is  to  say, 
interchangeable  conical  screws  fixed  by  a  nut  on  to 
the  end  of  metallic  handles  are  employed  in  dentistry 
to  extract  certain  teeth  having  only  one  root.  By 
replacing  the  screws  by  drills  and  reamers  we  get 
perfect  implements.  The  bolts  or  wedges  which 
we  are  going  to  use  to  fix  the  appliance  should  be 
got  ready  in  greater  number  than  those  actually 
used,  so  as  never  to  be  in  w^ant  of  one  when  operating. 

All  this  outfit,  arranged  in  a  special  box,  should 
be  sterilized  in  the  autoclave,  as  well  as  the  appliance 
and  its  retention  apparatus.  When  the  time  fixed 
for  the  procedure  arrives,  the  prosthesist,  having 
made  his  hands  aseptic,  will  arrange  on  a  specially 
designed  table  all  the  instruments  he  may  want. 
Everything  being  prepared  and  the  patient  anaes- 
thetized, an  intimate  collaboration  begins  between 
prosthesist  and  surgeon,  each  helping  the  other  in 
turn. 

Let  us  take  for  example  the  fixation  of  a  late 
internal  apparatus  for  restoration  of  a  partially 
resected  lower  jaw.  The  prosthesist,  who  must  be 
familiar  with  matters  surgical,  carefully  wraps  up 
the  operative  field  with  aseptic  compresses  so  as  to 
isolate  it  from  any  septic  contact,  especially  of  the 
hands  and  mask  of  the  anaesthetist.     The  surgeon 


244  INJURIES  OF  THE  FACE  AND  JAW 

makes  an  incision  following  the  lower  margin  of  the 
jaw,  and  while  the  prosthesist  helps  by  holding 
retractors  to  give  him  room,  he  strips  with  a  rugine 
the  bony  ends  which  are  to  support  the  appliance, 
and  he  attends  to  hsemostasis. 

In  the  second  stage  the  surgeon,  playing  the  part 
of  assistant,  in  his  turn  holds  the  retractors.  The 
prosthesist  applies  the  apparatus  to  the  bony  ends, 
and  adjusts  it  rapidly,  here  shortening  one  end  of  the 
splint  with  a  blow  of  the  chisel,  there  correcting  a 
faulty  curve  with  the  squeeze  of  the  pincers.  The 
appliance  being  fitted,  the  bone  is  to  be  trephined, 
always  passing  the  drill  through  the  holes  made  in 
the  metal  splint  so  that  the  trephining  should  cor- 
respond exactly  to  them.  We  place  for  choice  two 
bolts  at  each  end  of  the  splint,  so  as  to  insure  a  greater 
firmness.  The  rods  of  these  bolts  being  engaged  in 
the  holes  made  in  the  appliance  and  in  the  bone 
beneath,  we  proceed  to  screw  on,  as  fast  as  possible, 
the  nuts.  This  is  certainly  the  most  worrying  and 
difficult  stage,  for  the  blood  which  hides  the  view 
of  the  mass  of  muscles  above  the  hyoid,  and  handi- 
caps the  free  movements  of  the  fingers,  sometimes 
greatly  hinders  the  fixing  of  the  button  which  is  to 
be  applied  to  the  deep  surface  of  the  jaw.  It  is  a 
question  of  fumbling — and  of  patience.  Whenever 
possible  we  shall  strive,  so  as  to  minimize  this  diffi- 
culty, to  pass  from  within  outwards  the  rod  of  a 
bolt  furnished  with  a  fixed  head.  Then  we  have 
only  to  screw  on  the  outside  nut,  and  shall  avoid 
the  slow  and  tiring  manoeuvres  required  to  fix  a 
nut  on  the  inside  of  the  mandible. 


INSTR  UMENTA  TION  245 

The  appliance  having  been  firmly  fixed  to  the  bony 
ends,  the  prosthesist  resumes  the  part  of  assistant. 
In  this  third  and  last  stage  of  the  procedure,  the 
surgeon  stops  bleeding  points  with  particular  care, 
so  as  to  prevent  the  formation  of  a  hsematoma, 
which  can  easily  collect  around  a  foreign  body  placed 
between  the  jaw  segments.  Then  he  sews  up  the 
soft  parts,  preferably  in  several  layers.  The  skin 
will,  of  course,  be  sutured  without  providing  any 
drainage.  Union  should  be  obtained  by  first  in- 
tention. If  suppuration  ensues,  even  the  slightest, 
it  is  better  at  once  to  remove  the  appliance,  rather 
than  wait  for  the  impossible  healing  of  fistula  forma- 
tion. The  latter  inevitably  causes  the  extrusion  of 
the  foreign  body,  which  cannot  conceivably  be 
tolerated  after  it  finds  itself  in  an  infected  region. 
If,  on  the  other  hand,  we  have  succeeded  in  avoiding 
the  slightest  error  in  asepsis,  we  shall  have  the 
satisfaction  of  obtaining  a  perfect  restoration  and  a 
lasting  tolerance.* 

*  Sebileau  and  Delair. 


THIRD    PART 
TREATMENT   OF    FRACTURED    JAWS 

Fractured  jaws  can  only  be  treated  with  the  help 
of  special  appliances,  the  construction  of  which  calls 
for  technical  processes  related  to  the  art  of  dentistry. 
Although  in  such  cases  we  are  not  concerned  with 
prosthetic  appliances  properly  so  called,  the  study 
of  the  treatment  of  fractured  jaws  none  the  less 
finds  a  place  in  the  scope  of  this  book;  for  this  treat- 
ment is  a  branch  of  our  speciality. 


246 


SECTION    I 
FRACTURES  OF  THE  MANDIBLE 

Simple  Fractures. 

The  treatment  of  fractured  mandibles  is  very  variable, 
according  to  whether  we  are  dealing  with  fractures 
of  the  body,  the  ascending  rami,  the  coronoid  pro- 
cess, or  the  condyle.  Fractures  of  the  ascending  rami 
are  rare.  They  do  not  show  much  displacement, 
because  on  the  one  hand  the  masseter,  and  on  the 
other  hand  the  pterygoids,  constitute  natural  splints; 
and  the  mere  tonic  contraction  of  these  muscles 
assures  bony  coaptation.  Fractures  of  the  coronoid, 
the  condyle,  or  the  condylar  neck,  share  with  frac- 
tures of  the  ascending  ramus  the  advantage,  from 
the  point  of  view  of  treatment,  of  being  simple 
fractures.  [This  statement,  as  also  that  fractures 
of  the  ascending  ramus  are  rare,  does  not  apply  so 
much  to  gunshot  injuries. — Tr.] 

Fractures  of  the  alveolar  margin  and  those  of  the 
body  of  the  mandible  present,  on  the  contrary,  this 
common  characteristic:  that  they  are  usually,  if 
not  invariably,  compound,  and  therefore  infected. 
This  complication  depends  on  the  peculiar  anatomical 

247 


248  INJURIES  OF   THE  FACE  AND  JAW 

features  of  the  region — namely,  that  the  gingival 
mucosa  in  the  latter  situation  is  as  a  rule  torn  when 
the  fragments  are  displaced,  because  of  the  adherence 
of  mucosa  to  periosteum.  The  focus  becomes  in- 
fected all  the  easier  because  this  fracture  is  com- 
pound on  the  buccal  aspect,  which  is  essentially 
septic.  These  considerations  are  of  the  greatest 
interest  when  we  have  to  choose  a  mode  of  treatment 
for  a  fracture  of  the  lower  jaw. 

The  fracture  of  the  ascending  rami,  of  the  condylar 
neck  or  condyle  itself,  simple  fractures  with  little 
or  no  displacement,  heal  easily  and  with  very  little 
bony  loss.  The  wearing  of  a  chin  bandage  for  a 
few  days,  wdth  rest,  constitute,  in  fact,  in  many  cases 
the  whole  treatment. 

Compound  Fractures. 

It  is  quite  otherwise  with  fractures  of  the  body 
of  the  jaw,  compound  fractures,  infected,  and  some- 
times presenting  considerable  displacement.  In  fact 
we  know  that,  although  a  fracture  in  the  mid-line 
may  not  produce  any  displacement,  it  is  not  the 
same  with  lateral  fractures,  simple  or  comminuted. 
In  such  cases  the  fragments  are  drawn  in  opposite 
directions  by  the  muscles  inserted  into  them.  In 
a  lateral  fracture  of  the  body  of  the  jaw,  the  posterior 
fragment  is  displaced  upwards  and  backwards;  the 
anterior  fragment,  on  the  contrary,  is  directed  in- 
wards, backwards,  and  downwards.  In  a  double 
lateral  fracture  of  the  horizontal  portion  there  is  a 
median  segment  which  swings  very  freely  downwards 
and^backwards. 


SUTURE  OF  BONE  249 

Thus,  fractures  of  the  body  are  often  difficult  to 
keep  reduced,  and  it  is  doubtless  for  this  reason  that 
we  owe  the  legion  of  opinions  as  to  their  treatment. 
The  various  treatments  proposed  can  meanwhile  be 
classified  under  three  heads: 

1.  Suture  and  ligature  of  fragments. 

2.  Bandages,  slings,  and  dental  ligatures. 

3.  Appliances  proper. 


CHAPTER  I 
SURGICAL  METHODS 

I.  Suture  of  Bone. 

To  carry  out  this  operation  we  can  approach  the 
bed  of  the  fracture  by  two  routes — buccal  and 
cutaneous.  Holes  are  drilled  through  the  fragments, 
taking  care  to  avoid  tooth  roots.  Wires,  engaged 
in  these  perforations,  assure  reduction  and  good 
coaptation  of  the  pieces  thus  drawn  together.  As 
a  rule  we  use  metal  wires,  for  preference  silver. 
The  two  ends  of  the  wire  can  be  twisted  together 
(Carter's  method),  or  each  one  twisted  separately 
in  a  spiral,  after  they  have  passed  through  the  bone 
(method  of  Hughes  Thomas).  By  this  we  succeed 
in  re-establishing  the  continuity  of  the  broken 
mandibular  axis,  but  the  functional  results  obtained 
after  union  are  often  far  from  satisfactory.  In  fact, 
it  is  just  to  level  two  serious  criticisms  against  suture 
of  bone  (which  is  considered  by  some  surgeons  the 


250  INJURIES  OF   THE  FACE  AND  JAW 

treatment  of  choice  for  fractures  of  the  body  of  the 
jaw):  (i)  Risks  of  infection;  (2)  inabihty  to  re- 
estabUsh  with  certainty  the  functional  integrity  of 
the  jaw  from  the  point  of  view  of  the  interdental 
articulation. 

I.  Risks  of  Infection. — They  are  obvious.  We  are 
dealing  with  a  fracture  in  an  infected  focus,  open 
into  the  mouth.     To  suture  is  to  put  a  foreign  body 


Fig.   118. — Hughes  Thomas's  Method. 


;Heath.) 


A,  B,  Suture  wire  twisted  at  its  ends;  a,  b,  rod,  spht  at  the 
end,  for  twisting  the  wire. 

into  this  septic  area.  This  is,  therefore,  a  certain 
way  of  insuring  an  indefinite  suppuration  to  the 
extent  of  the  extrusion  of  the  foreign  body.*  It  is 
running  an  ever-present  risk  of  forming  a  large  or 
small  sequestrum,  involving  (after  it  is  cast  off)  a 
shortening  of  the  dental  arch.     One  of  us  has  ob- 

*   G.  Lemerle,  "  Contribution  to  the  Experimental  Study 
of  Internal  Prosthesis,"  These  Paris,  1907. 


SUTURE  OF  BONE 


251 


served  two  accidents  of  this  sort  in  cases  of  suture 
for  fracture  of  the  horizontal  ramus.  Bony  suture, 
then,  simply  on  account  of  its  septicity,  constitutes 
a  bad  operation. 


Fig.   119. — Hughes  Thomas's  Method:  Mode  of   tightening 
the  Wire.      (Mahe.) 

2.  Bony  siUure  is  incapable  of  re-establishing  with 
certainty  the  functional  integrity  of  the  jaw  from  the 
point  of  view  of  the  interdental  articulation.  The 
treatment  of  a  limb  fracture  should  be  directed,  not 


Fig.  120. — Wire  Tightener  of  Carter.      (Mahe.) 


merely  to  reform  the  continuity  of  the  broken  dia- 
physis,  but  also  to  assure  the  preservation  of  the 
functional  value  of  the  wounded  member.  This 
applies  to  a  fracture  of  the  leg,  when  the  surgeon's 


232  INJURIES  OF  THE  FACE  AND  JAW 

efforts  should  concentrate  on  preventing  any  limp. 
If  this  result  is  not  attained,  the  patient  after  recovery 
still  remains  maimed. 

The  same  reasoning  applies  to  fractures  of  the 
mandible.  Thus,  we  must  make  an  effort  to  preserve 
its  functional  integrity — that  is,  its  power  of  masti- 
cating well.  To  obtain  this  result,  it  is  of  cardinal 
importance  to  make  certain  that  the  interdental 
articulation  is  exactly  reconstituted. 

"If  it  eventuates  in  a  deformity  of  one  of  the 
dental   arches,    this   deformity — howbeit    limited   to 


Firi.    121. — Tightening    the    Wire    with    an    Ordinary    Pair 

of  Forceps. 

one  point,  with  an  arch  intact  as  regards  the  number 
of  teeth — upsets  the  complex  and  delicate  articula- 
tion of  the  two  jaws;  mastication  is  hindered,  and 
the  feeding  of  the  patient  handicapped.  And  a 
fortiori,  if  the  deformity  consists  of  an  alteration 
in  the  parabolic  intercuspid  curve  of  one  of  the 
dental  arches  (the  active  line  of  mastication),  or  in 
a  horizontal  torsion  of  the  plane  of  mastication  of 
this  arch,  the  same  results  are  even  more  noticeable. 
Of  this  argument  the  logical  conclusion,  at  which  we 
wish  to  arrive,  and  which  seems  clearly  to  have 
been  scorned  by  most  surgeons,  is :  That  a  fracture 


SUTURE  OF  BONE 


253 


of  the  mandible,  being  practically  a  dislocation  of 
the  dental  arch,  is,  as  regards  prognosis,  dependent 
less  on  the  operative  than  on  the  functional  result. 
[The  itahcs  are  the  Translator's.]  And  that  the 
'  surgical  procedure  ' — that  phrase  to  which  so  much 
is  sacrificed — should  consist,  not  in  preventing 
pseudarthrosis  and  obtaining  a  healed  and  solid  jaw,. 


Fig.   122. — Sling  Bandage. 


but  in  reconstituting  a  dental  arch  conforming  as 
nearly  as  may  be  to  its  antagonist,  so  that  the  invalid 
may  eat."'^     [Translator's  italics.] 

Bony  suture  cannot  insure  this  functional  result,  for 
though  it  can  recreate  bony  continuity,  it  is  mani- 

*  Mahe,  "  Critical  Essay  on  the  Treatment  of  Fractured 
Mandibles,"  These  Paris,  1900,  p.  25. 


254  INJURIES  OF  THE  FACE  AND  JAW 

festly  insufficient  to  establish  exactly  the  interdental 
articulation,  and  we  have  seen  that  on  the  integrity 
of  this  latter  depends,  above  all,  the  function.  A 
septic  operation  and  one  offering  certain  chances  of 
infective  sequelae,  an  operation  incapable  of  assuring 
the  functional  restoration  of  the  damaged  jaw,  bony 


'/y^Mtr' 


Fig.  123. — Chin  Jaw  Bandage. 

The  numbers  show  the  order  in  which  the  turns  of  the  bandage 
should  be  made. 

suture  should  be  relegated  to  the  past  or  only  used 
rarely  and  exceptionally  in  treatment.  In  all  cases 
we  can  do  better  than  suture.  We  consider  that 
the  use  of  metal  splints  screwed  on  to  the  bone  will 
give  better  results  than  wires,  and  that  silver  is 
always  the  metal  of  choice. 


BANDAGES  255 

II.  Ligature  of  Bone. 

This  was  practised  for  the  first  time  by  Baudens, 
who  passed  a  wire  loop  round  the  fragments,  in 
immediate  contact  with  them,  and  tied  them  to  the 
teeth  within  the  mouth.  Beranger-Feraud  later 
recommended  this  plan.*  It  is  liable  to  th-^,  same 
criticisms  as  bony  suture,  and  we  will  not  repeat 
them. 


CHAPTER  II 
PROVISIONAL  APPARATUS 

I.  Bandages. 

The  lower  jaw  is  bandaged  with  a  linen  bandage 
about  a  yard  long  and  4  inches  wide.  In  its  middle 
we  remember  to  make  an  opening  into  which  the  chin 
fits.  Also  each  end  is  torn  lengthwise  to  within 
4  inches  of  the  chin  window.  The  bandage  being 
applied  to  the  chin,  the  two  strips  at  each  end  are 
knotted,  one  pair  over  the  vertex,  the  other  over  the 
neck ;  then  they  are  again  tied  together  in  the  middle 
line  to  prevent  them  from  slipping  (Fig.  122). 

The  "  chevestre  "  is  a  more  complicated  bandage, 
of  which  the  annexed  figures  give  a  better  idea  than 
any  description  (Fig.  123). 

Gosselin,  and   more  recently  Ponroy,|    advocated 

*  Beranger-Feraud,  "  Treatise  on  Direct  Immobilization 
of  Bony  Fragments  in  Fractures,"  Paris,  1870. 

t  Ponroy,  "  Treatment  of  Fractured  Mandibles  by  Elastic 
Bandages,"  These  Paris,  1903. 


256  INJURIES  OF  THE  FACE  AND  JAW 

an  elastic  bandage  instead  of  linen  for  the 
"  chevestre."  At  the  present  time  these  bandages 
are  an  inferior  mode  of  treatment  for  broken  jaws, 
and  quite  inadequate.  And,  apart  from  median 
fractures  without  displacement,  we  cannot  regard 
them  as  a  means  of  splinting  which  will  comfort  the 
patient  or  temporarily  retain  the  fragments. 

II.  Slings. 

The  simple  sling  consists  essentially  of  a  chin- 
band  provided  with  four  ends  cut  out  of  the  same 
material.  If  the  chin-strap  and  ends  are  not  of  the 
same  material,  we  call  it  a  "  compound  sling." 
Leblanc*  uses  for  the  chin-band  plastered  muslin, 
and  strips  of  rubber  as  retaining  straps. 

Hamilton,  t  whose  method  is  still  followed  in 
England,  adopts  a  chin-band  of  leather,  maintained 
by  traction  on  a  head-band  fixed  on  to  a  circular 
strap  which  passes  round  the  head,  encircling  the 
forehead  and  occiput. 

BouissonJ  fits  to  his  chin-band  two  traction  straps. 
These  straps  are  elastic;  one  leaves  the  chin-strap 
and  is  fixed  to  the  headpiece  in  front  of  the  ear,  the 
other  starts  from  the  same  point  and  is  fixed  behind 
the  head. 

*  Leblanc,  "  Contribution  to  the  Treatment  of  Fractured 
Mandibles,"  These  Paris,  1897. 

I  Hamilton,  "  Practical  Treatise  on  Fractures  and 
Dislocations,"  Poinsot  translation,  1884,  p.  415. 

\  Bouisson,  "  Description  of  a  New  Appliance  for  the 
Treatment  of  Fractures  of  the  Mandible  "  (Journ.  de  la  Soc. 
de  nied.  pratique  de  Montpellier,  1843,  vii.,  106-116). 


SLINGS  25; 


Koy*  modified  Bouisson's  sling  by  impivjving  the 
traction  staples  of  the  chin-band  (see  Fig.  124). 

Dubreuilf  has  made  use  of  a  curious  appliance 
consisting  of  a  metal  circle  applied  to  the  auriculo- 
bregmatic  line  of  the  head.  It  has  two  branches 
taking  their  purchase  from  the  sides  of  the  lower 
jaw.  The  ends  of  the  branches  are  joined  by  a  screw 
which  permits  of  their  approximation  to  maintain 


Fig.   124. — Bouisson's  Sling  modified  by  M.  Roy. 

coaptation,  in  cases  of  fractures  round  about  the 
symphysis.  More  complicated  than  bandages,  slings 
do  not,  however,  give  any  more  security,  as  a  method 
of  treatment  of  fractured  jaws  accompanied  by 
displacement  of  the  fragments. 

*    Roy,  Revue  intevnat.  (Todontol.,  1892,  p.  114. 

j  Dubreuil,  "  New  Method  of  Treatment  of  Fractures  of 
the  Mandible,  when  the  Fracture  passes  through  the  Sym- 
physis or  in  its  Neighbourhood  "  {Gazette  des  hopitanx, 
1872,  xiv.,  p.  154). 

17 


2S8 


INJURIES  OF  THE  FACE  AND  JAW 


III.  Interdental  Ligatures. 

The  interdental  ligature  can  be  contrived  in  two 
ways: 

I.  A  metal  ligature  joining  the  teeth  immediately 
abutting  on  the  fracture,  from  one  segment  of  the 


Fig.   125.— Intermaxillary  Ligature:  Leblanc's  Process. 

jaw  to  the  other.  This  type  of  ligature  approximates 
the  extremity  of  the  fragments,  but  is  a  poor  correc- 
tive of  vertical  displacements. 

2.  A  ligature  joining  the  lower  to  the  upper  teeth, 
the  upper  jaw  being  thus  regarded  as  a  splint.  The 
fracture,  immobilized  and  corrected,  heals  in  this 
position,  the  mouth  being  kept  in  a  state  of  occlusion. 

Guillaume  of  Salicet,  Italian  surgeon  of  the  thir- 
teenth  century,    already   used   this   method.     Some 


INTERDENTA L  LIGA  T  URES 


^59 


years  ago  Leblanc*  renewed  this  mode  of  treatment, 
and  published  an  interesting  memoir  on  the  subject. 
To  describe  the  principle  of  this  ligature,  let  us 
suppose  ourselves  concerned  with  a  wounded  man 
in  possession  of  all  his  teeth,  and  exhibiting  a  double 
fracture  which  isolates  a  median  fragment. 

"It  is  quite  simple  to  place,"  says  Leblanc,  "  at 
each  end  of  the  fragment,  a  silver  wire  around  a 
tooth,  to  repeat  this  on  the  homologous  teeth  of  the 


Fig.   126. — Intermaxillary  Ligature:  Leblanc's  Process. 

upper  jaw,  to  approximate  the  lower  segment  so 
that  it  articulates  very  exactly  with  the  upper  teeth, 
and  to  join  up  in  pairs  the  wires  previously  placed." 
Angle!  has  treated  many  cases  of  fractured  man- 
dibles by  a  similar  process,  but  he  uses,  as  a  point 

*  Leblanc,  "  Contribution  to  the  Treatment  of  Fractures 
of  the  Mandible,"  These  Paris,  1897. 

t  Angle,  "  Some  of  the  Principles  to.  be  considered  in 
the  Treatment  of  the  Teeth  and  Fractures  of  the  Maxillary 
Bones  "  {Dental  Rev.,  Chicago,  1890,  pp.  380-383).  See 
also  Med.  Rec,    New  York,  1890,  pp.  611-613. 


26o  INJURIES  OF  THE  FACE  AND  JAW 

d'appid  on  the  teeth,  metal  bands  cemented  on. 
A  metal  wire  then  joins  (by  the  bands  as  inter- 
mediaries) the  upper  and  lower  teeth,  and  puts  the 
dental  articulation  in  a  state  of  occlusion.  Thus 
we  obtain  immobilization  and  correction  of  the 
fragments.  Various  objections  have  been  made  to 
Leblanc's  method,  which,  for  that  matter,  are  not 
always  justified.  We  may  examine  them  in  turn, 
for  they  will  recur  again  to  some  extent  later,  apropos 
of  all  the  methods  of  keeping  the  jaws  in  a  state  of 
occlusion. 

1.  Difficulty  in  feeding  the  wounded  man.  In 
reality,  the  invalid  is  deprived  of  solid  food;  but 
experience  has  shown  that  there  is  always  enough 
room  between  the  teeth  to  allow  him  to  take  soup, 
milk,  or  other  liquid  foods. 

2.  Difficulty  experienced  in  speaking.  Here  again, 
according  to  Leblanc,  is  a  purely  theoretical  objection, 
for  everyone  can  observe  for  himself  that  it  is  possible 
to  pronounce  any  word  without  separating  the 
teeth. 

3.  The  ligature  loosens  the  teeth.  This  is  only 
strictly  true  in  ligaturing  to  teeth  of  the  same  jaw. 

4.  The  metal  wires  irritate  the  gum,  and  soon 
provoke  a  local  infection.  This  is  only  true  when 
the  ligatures  are  malplaced. 

5.  The  metal  wires  cause  pain.  The  practice  of 
orthodontia,  in  which  ligatures  are  constantly  used, 
proves  that  there  is  nothing  in  this  objection. 

6.  Finally,  the  same  answer  (see  No.  5)  may  be 
made  to  the  last  accusation,  that  the  ligature  w^ars 
away  enamel  and  initiates  caries. 


FRACTURE  APPLIANCES  261 

In  our  opinion,  there  is  only  one  objection  carr^dng 
any  real  weight,  and  that  is  the  following :  The  patient 
thus  ligatured  stays  for  forty  or  fifty  days  without 
opening  his  mouth,  of  which  for  weary  weeks  any 
toilette  is  impossible,  since  the  state  of  forced  oc- 
clusion of  the  jaws  only  allows  the  vestibular  surface 
of  the  teeth  to  be  brushed.  This  is  a  very  real 
drawback  to  the  method,  all  the  more  so  in  that 
we  are  generally  concerned  with  a  compound,  in- 
fected fracture,  demanding  a  strict  hygienic  ritual. 

In  any  case,  Leblanc's  method  happens  to  be 
excellent  in  that  its  execution  is  very  simple,  it 
requires  no  special  outfit,  and  it  is  available  for  any 
practitioner  not  a  specialist.  For  these  reasons, 
and  if  we  imagine  a  patient  provided  with  all,  or 
nearly  all,  his  teeth,  far  from  any  prosthetic  re- 
sources, this  treatment  of  fractured  jaws  deserves 
to  be  retained.  It  has  at  least  this  immense  ad- 
vantage over  bony  suture,  that  it  assures  a  con- 
solidation with  preservation  of  a  good  interdental 
occlusion,  and  as  a  result  a  recovery  with  func- 
tional integrity  of  the  jaw. 


CHAPTER  III 

FRACTURE  APPLIANCES  PROPER 

They  are  extremely  numerous,  and  for  this  reason 
difficult  to  classify.     We  shall  divide  them  as  follows : 
I.  Appliances  fixed  without  previously  taking  an 
impression. 


262  IX JURIES  OF   THE  FACE  AND  JAW 

2.  Appliances  requiring  an  impression  and  made 
to  a  corrected  mould. 

These  latter  fall  under  three  subdivisions: 

{a)  Appliances  consisting  of  double  splints  (one 
for  the  chin,  and  one  dental). 

(&)  Appliances  consisting  of  double  splints  (upper 
dental  and  lower  dental). 

(c)  Appliances  consisting  of  a  single  dental  splint. 

I.  Appliances  fixed  without  previously  taking  an 
Impression. 

These  have  a  special  historical  interest,  and  present 
the  common  feature  of  taking  their  support  from 
the  dental  arch  and  lower  part  of  the  jaw.  According 
to  Malgaigne,*  the  idea  of  using  a  double  splint 
belongs  to  Choppart  (1780),  who  proposed  an  ap- 
paratus comprising  a  dental  splint  formed  of  a  plate 
of  cork  or  lead,  joined  by  metal  hooks  which  curve 
round  to  the  outside  to  a  submental  splint.  This 
idea  was  taken  up  by  Ruthenick  in  Germany.  He 
perfected  an  appliance  in  which  he  utihzed  a  metal 
dental  gutter  equipped  with  two  rods  which  were 
attached  to  a  submental  plate,  gutter  and  plate 
being  covered  with  absorbent  bark.  Kluge,  Lons- 
dale, Jousset,t  employed  the  same  principle. 

Houzelot's  original  arrangement  enabled  the  sur- 
geon to  regulate  the  splint  as  he  liked.  His  ap- 
paratus has  for  a  long  time  been  classical,  and  on 
this  ground  deserves  a  more  detailed  description. 

*  Malgaigne,  "  Treatise  on  Fractures  and  Dislocations," 
i.,  p.  371,  1847. 

I   Jousset,  Gazette  medicale  de  Paris,  1833. 


HOUZELOT'S  APPARATUS  263 

Houzelot's  Apparatus  (1827).* — 'This  consists  of  a 
chin  splint  and  a  dental  splint,  and  we  shall  find  this 
principle  of  a  double  splint  (internal  and  external) 
in  numerous  appliances  since  invented.  Houzelot 
himself  gave  the  following  description  of  his  inven- 
tion : 

"  This  apparatus  comprises — i.  A  metal  rod,  which 
I  call  '  maxillo -dental,'  formed  of  two  parts.  The 
first,  vertical,  presents  in  its  lower  two -thirds  a 
longitudinal  window  or  groove.  The  second,  hori- 
zontal, is  soldered  at  right  angles  to  the  first,  and 
directed  backwards  and  forwards,  lying  in  the  mouth. 

"  2.  A  small  upper  plate,  dental,  because  it  takes 
its  point  d'appiii  from  the  teeth.  It  is  soldered 
transversely  to  the  free  end  of  the  horizontal  part  of 
the  maxillo -dental  rod.  It  is  plane  on  both  surfaces, 
semicircular  to  accommodate  itself  to  the  arrange- 
ment of  the  dental  arch,  and  pierced  by  holes. 

"3.  Corks  are  placed  on  the  surfaces  of  the  plate. 
The  lower  has  deep  recesses  to  receive  the  teeth. 
The  upper,  of  very  slight  thickness,  prevents  the 
immediate  contact  of  the  mucous  membrane  on  the 
metal  of  which  the  appliance  is  formed. 

"  4.  Some  small  wooden  pegs  pass  through  the 
cork,  and  are  received  in  holes  of  the  dental  plate, 
on  which  they  thus  fix  the  corks. 

"  5.  A  lower  or  maxillary  plate.  It  is,  in  fact,  on 
the  lower  border  of  the  maxilla  that  it  acts.     Slightly 

*  Houzelot,  "  Some  Considerations  on  Fracture  of  the 
Body  of  the  Mandible,  and  a  Description  of  a  New  Appliance 
to  retain  the  Fragments:  with  Notes  on  Supports,"  These 
Paris,  1827,  p.  15. 


264  INJURIES  OF  THE  FACE  AND  JAW 


Fig.   127. — Houzelot's  Fracture  Appliarxce  for  the  Mandible 

I,  Appliance  assembled;  2,  maxillary  plate;  3,  maxillo- 
dental  rod;  4,  dental  plate;  5,  key  or  spanner;  6,  nut; 
7,  upper  cork;  8,  lower  cork. 


HOUZELOT'S  APPARATUS  265 

concave  on  its  upper  rubber-covered  surface,  it 
receives  in  this  concavity  the  lower  margin  of  the 
maxilla,  which  it  presses  from  below  upwards. 
Received  by  a  narrow  quadrilateral  stalk  in  the 
window  which  we  have  seen  cut  in  the  vertical 
portion  of  the  maxillo-dental  rod,  it  is  movable  in 
this  window,  to  the  edges  of  which  it  is  fixed  by  means 
of  a  nut,  and  by  pressure  exercised  in  front  and 
behind.  The  nut  fits  on  to  a  screw-thread  on  the 
stalk  of  the  plate. 

"  6.  A  nut,  notched  at  two  opposite  points  of  its 
circumference,  which  receives  the  two  projecting 
parts  of  the  spanner  or  key  which  turns  it. 

"7.  An  appropriate  spanner  or  key. 

"  Application  of  the  Apparatus. — Having  reduced 
the  fracture  as  generally  described  in  textbooks,  the 
surgeon  first  of  all  places  the  dental  plate  on  the 
teeth,  which  are  received  into  the  canal  of  its  cork; 
it  is  so  applied  as  to  act  on  the  teeth  on  either  side 
of  the  fracture.  The  left  index  and  middle  fingers 
hold  it  in  this  position.  He  thus  engages  the  stalk 
of  the  maxillary  plate  in  the  vertical  window.  His 
left  thumb,  lying  on  the  lower  surface  of  this  plate, 
pushes  it  from  below  upwards  against  the  lower 
edge  of  the  bone,  which  it  should  compress ;  and  when 
the  pressure  is  strong  enough  (which  he  can  easily 
gauge,  since  his  own  fingers  are  making  the  pressure), 
then  the  right  hand  puts  on  the  screw  the  nut,  which 
he  turns  with  the  key.  By  tightening  he  thus  im- 
mobilizes the  lower  plate  on  the  window  in  the 
maxillo-dental  rod.  We  support  the  apparatus  by 
a  few  turns  of  a  bandage;  one  passes  from  chin  to 


266  INJURIES  OF  THE  FACE  AND  JAW 

occiput,  the  others  pass  beneath  the  chin  and  end 
above  the  vertex.  They  must  be  only  moderately 
tight." 

Such  is  the  apparatus  of  Houzelot,  and  its  mode 
of  application,  of  which  we  have  reproduced  the 
verbatim  description.  It  has  great  defects;  its 
dental  splint  is  too  short  and  can  hardly  ever  be 
used  except  for  fractures  of  the  anterior  part  of  the 
jaw.  Its  external  splint  does  not  wrap  round  the 
whole  curve  of  the  chin,  and  gives  an  insufficient 
support.  But  we  must  reflect  that  Houzelot's  first 
observation  dates  back  to  1826,  and  in  his  day  his 
appliance  constituted  a  considerable  advance  in  the 
treatment  of  fractured  mandibles.  Lastly,  his  prin- 
ciple— an  internal  and  an  external  splint — is  used 
in  a  large  number  of  appliances  invented  one  after 
the  other  from  his  day  to  ours. 

Appliance  of  Morel-Lavallee*  (1862). — This  is 
actually  a  transition  between  the  appliance  of 
Houzelot  and  those  which  are  made  after  taking  a 
dental  impression.  Morel-Lavellee's  appliance  was 
made  in  the  following  way:  A  roll  of  gutta-percha, 
softened  in  warm  water  and  placed  in  a  metal  gutter, 
was  applied  to  the  teeth,  which  thus  fitted  into  it 
exactly.  To  the  dental  splint  thus  obtained  was 
added  a  spring  made  of  a  fairly  thin  steel  sheet,  of 
which  the  upper  end,  forming  a  plateau,  lay  against 
the  gutta  mould,  into  which  it  was  implanted  by 
small  points.     The  other  end  of  this  spring,   fixed 

*  Morel-Lavallee,  "  Gutta-percha  Appliance  for  Frac- 
tured Jaws "  {Bulletin  gen.  de  ther.,  Paris,  1862,  iv.,  iii. 
pp.  200,  248,  252). 


MUX'S  APPLIANCE 


267 


to  a  concave  pad,  applied  this  pad  as  an  external 
splint  beneath  the  chin,  which  gave  it  its  point 
d'appin.  Although  an  improvement  on  Houzelot's 
apparatus  (having  a  better  adaptation  of  its  splints), 
the  appliance  of  Morel-Lavallee  has  the  fault  of  only 


Fig.   128. — Simple  Appliance  for  Fractured  Mandible. 

(Nux.) 

partly  correcting  the  displacements  of  the  fragments. 
For  at  the  time  of  application  of  the  softened  rubber 
the  correction  is  not  always  put  beyond  all  doubt. 
Nux's  Appliance.*— This  consists  of  two  parts : 

*  Nux,   "  A  Simply-made  Appliance  for  Fracture  of  the 
Mandible  "  [Odontologie,  Aout,  1907,  p.  132). 


268  INJURIES  OF  THE  FACE  AND  JAW 

1.  An  impression  tray  with  a  flat  base,  covered 
with  godiva  or  Stent's  up  to  flush  with  its  edge. 

2.  A  sphnt  of  malleable  iron  wire,  round,  3  mm. 
thick  and  about  30  cm.  long.  This  wire  is  shaped 
in  a  vice  in  the  form  of  a  Y.  The  branches  are 
gently  arched  to  hug  the  contour  of  the  jaw;  and  the 
stem  of  the  Y  forms  a  sort  of  handle  which  is  super- 
posed on  the  handle  of  the  impression  tray  (Nux). 
To  fit  this  appliance  is  simplicity  itself:  The  tray, 
being  filled  with  godiva  (previously  softened  with 
warm  water),  is  introduced  into  the  mouth  and 
pressed  on  to  the  dental  arch  by  the  index-finger  of 
each  hand;  while  the  thumb,  placed  on  the  edges 
of  the  jaw,  lever  the  fragments  so  as  to  bring  them 
into  the  best  possible  contact.  We  get  the  teeth 
well  into  the  godiva  by  making  the  patient  at  once 
close  his  mouth,  pressing  the  chin  upwards  with  the 
palm  of  the  hand.  When  the  godiva  is  hard,  we  fix 
the  iron  wire  loop  on  to  the  handle  of  the  impression 
tray  b}^  means  of  a  nut.  The  whole  is  supplemented 
by  a  chin-plate  fixed  by  a  bandage  passing  up  on 
each  side  from  its  lateral  branches. 

Nux  advised  against  letting  the  impression- 
material  overflow  the  tray,  which  would  press  back 
the  gums  and  hinder  the  antiseptic  washes  which  are 
necessary  in  cases  of  compound  fracture.  So  the 
godiva  should  come  to  an  end  at  the  gingival  margin, 
leaving  the  mucosa  uncovered  as  far  as  possible. 
For  that  matter,  it  is  easy  to  trim  it  with  a  hot 
spatula.  Before  placing  the  appliance,  it  is  wise  to 
file  down  the  lower  edges  of  the  impression  tray  in 
the  mid-line,  to  avoid  the  irritation  which  the  gutter 


APPLIANCES  MADE  ON  A   MOULD  269 

might  cause  to  the  fraenum  of  the  tongue  and  to 
the  lower  hp.  Lastly  we  remove  with  a  file  a  part 
of  the  upper  and  outer  angle  of  the  impression  tray, 
and  bore  a  hole  in  it  opposite  the  premolars.  By 
this  expedient  the  upper  molars  can  bite  into  the 
interior  without  hitting  against  the  gutter,  the 
premolars  oppose  more  easily,  and  the  articulation 
of  the  teeth  is  separated  as  little  as  possible. 

It  has  a  great  disadvantage  (for  that  matter, 
recognized  by  its  author) — namely,  that  it  does  not 
enable  us  to  place  beyond  all  doubt  the  integrity  of 
the  interdental  articulation.  Thus,  it  is  liable  to 
the  same  objection  as  the  appliance  of  Morel-Lavallee, 
with  which  it  can  be  classed,  since  its  manufacture 
does  not  call  for  the  previous  taking  of  a  mould. 
We  must  in  any  case  recognize  that  Nux's  appliance 
is  an  ingenious  means  of  making  quickly  a  temporary 
or  first-aid  contrivance  to  immobilize  the  jaw.  Mean- 
while we  shall  be  waiting  to  apply,  in  every  case 
where  this  is  possible,  a  treatment  capable  of  assuring 
with  certainty  the  preservation  of  the  interdental  bite. 

"  It  is  essential,"  says  CI.  Martin,  "  not  that  the 
appliance  moulds  itself  on  fragments  more  or  less 
reduced,  hut  that  the  fragments  mould  themselves  on  to 
an  appliance  which  is  a  hollow  {or  negative)  replica 
of  the  shape  of  the  dental  arch  as  it  was  before  fracture."* 

II.  Appliances  which  necessitate  the  Taking  of  an 
Impression,  and  made  on  a  Corrected  Mould. 

The  taking  of  a  mould  of  the  dental  arches  previous 
to    making   a   retention    apparatus    marks   a   great 

*  Martin,  Rev.  de  chir.,  1887,  v.,  No.  xi. 


270  INJURIES  OF  THE  FACE  AND  JAW. 

advance.  This  principle  is  common  to  all  up-to-date 
appliances  with  single  or  double  splints,  however 
diverse  their  nature.  Let  us,  then,  study  the  prin- 
ciple before  passing  on  to  the  appliances. 

Taking  an  Impression. — This  depends  on  the  same 
laws  as  govern  the  taking  of  an  ordinary  impression. 
Nevertheless,  the  obstacles  are  greater,  and  are 
referable  to  the  pain  caused  to  the  patient  by  the 
manoeuvres  of  instrumentation,  and  to  the  greater 
or  less  difficulty  which  he  experiences  in  widely 
opening  his  mouth.  For  narrowing  of  the  jaw- 
opening  almost  always  accompanies  fractures  of  the 
lower  jaw,  at  any  rate  during  the  few  days  immedi- 
ately following  the  injury.  Wax,  godiva,  or  plaster, 
may  be  employed;  if  we  elect  the  latter,  we  shall 
have  to  introduce  it  at  the  precise  moment  chosen, 
some  seconds  before  taking  the  impression.  This 
precaution  is  to  prevent  an  admixture  of  saliva^ 
which  is  always  very  copious  in  these  cases,  and  can 
rob  the  impression  of  its  finish..  Godiva  is  preferable 
to  plaster  in  this  case,  on  account  of  the  pain  produced 
by  the  plaster  when  it  has  hardened ;  and  we  separate 
the  material  from  the  parts  to  be  moulded.  The 
impression  (except  in  certain  rare  and  very  difficult 
cases  where  we  have  to  proceed  by  partial  moulds) 
is  to  be  taken  in  one  piece.  Above  all,  it  must  be 
complete.*  We  need  not  take  count  of  the  dis- 
placement of  the  fragments,  whatever  this  may  be; 
for  the  displacement  has  no  importance,  once  we 
have   it    reduced    on   the    model.-\     During   the   pro- 

*   Cl.  ^Martin,  Rev.  de  chir.,  1S87,  vii.,  No.  xi. 
7   P.  Dubois,  Odontologie,  Juin,  1894,  p.  325. 


RECONSTITUriON  OF  THE  MODEL  271 

cedure  of  taking  the  impression,  an  assistant  holds 
up  the  chin,  so  as  to  diminish  the  pain  (consequent 
on  the  displacement  of  the  fragments)  by  exercising 
the  necessary  pressure.  The  impression  of  the  two 
jaws  is  indispensable  for  carrying  out  the  two  follow- 
ing operations: 

Reduction  of  the  Fracture  on  the  Model,  and 
Reconstitution  of  the  Model. — Having  cooled  down 
the  impressions  and  stripped  off  the  models,  we 
must  first  of  all  proceed  to  the  reduction  of  the 
fracture  on  the  model,  which  at  this  moment  re- 
presents the  jaw  with  its  fragments  displaced.  With 
a  saw  we  divide  the  model  at  the  position  of  the 
fracture.  The  section  is  to  be  a  good  deal  widened 
at  its  base — that  is  to  say,  at  the  part  corresponding 
to  the  floor  of  the  mouth.  This  is  so  as  not  to  be 
hindered  afterwards  in  the  coaptation  of  the  frag- 
ments. Then  we  fit  the  most  important  fragment 
to  the  upper  jaw,  to  try  and  obtain  the  exact  articula- 
tion of  this  fragment.  The  wear  and  tear  of  the 
teeth  produced  by  the  points  of  contact,  that  pro- 
duced by  a  pipe-stem  in  a  smoker,  are  guides  which 
help  us  to  find  the  articulation.  In  difficult  cases 
we  examine  minutely  the  teeth  impressions  in  the 
plaster  to  find  there  traces  of  wear,  which,  however 
faint,  are  precious  guides. 

When  the  articulation  of  the  first  fragment  is 
adjusted,  we  fix  together,  with  melted  wax,  the 
models  in  their  proper  relations.  Then  we  begin 
a  similar  operation  on  the  second  fragment.  This 
put  in  place  and  stuck  to  the  first,  it  only  remains 
to  pour  plaster  into  the  solution  of  continuity  between 


272  INJURIES  OF  THE  FACE  AND  JAW 

the  two  fragments.  The  plaster  answers  equally 
well  for  the  reconstitution  of  the  model  and  the 
intimate  consolidation  of  its  fragments.  The  model 
is  next  trimmed,  the  excess  of  plaster  which  has 
welled  over  on  to  the  jaw,  in  the  neighbourhood  of 
the  fracture,  removed,  and  the  surface  levelled. 
We  now  have  a  reduced  model — that  is,  the  exact 
mould  of  the  mouth  before  the  fracture.  The  con- 
struction of  an  appliance  for  a  fracture  has  the 
peculiarity  that  it  can  never  be  tried  before  placing 
it.  It  is  therefore  necessary  to  encompass  oneself 
with  minute  precautions,  so  that  it  shall  make  contact 
with  the  parts  on  which  it  will  rest,  without  damaging 
them,  and  also  that  it  should  fit  as  exactly  as  possible. 

Preparation  of  the  Model. — The  best  way  to  fulfil 
these  conditions  is  to  "  prepare  "  the  model  on  the 
fracture,  as  soon  as  the  latter  is  reduced.  This 
preparation  consists  in  exaggerating  the  size  of  the 
tubercles  of  all  the  teeth  as  well  as  the  projecting 
ridges  of  the  mouth  on  which  the  appliance  will  rest. 
This  is  effected  by  liquid  plaster  or  by  means  of  small 
drops  of  melted  wax.  Only  the  proximal  spaces 
ought  to  be  respected,  in  such  a  way  as  to  assure  the 
retention  of  the  appliance,  while  allowing  it  to  be 
easily  placed.  This  sort  of  preparation  is  indis- 
pensable to  apparatus  made  with  troughs,  whether 
they  be  made  of  metal  or  rubber.  It  is  on  this 
model  that  we  proceed  to  the  combination  and 
fashioning  of  the  retention  appliance. 

In  a  case  where  there  are  no  remaining  teeth  in 
the  upper  jaw,  or  if  the  number  of  these  teeth  is 
inadequate  to  reconstruct  the  articulation,  the  opera- 


DOUBLE  SPLINT  APPLIANCES  27,-? 

tion  is  simplified  in  this  sense:  that  it  suffices  to 
reduce  the  fracture  in  such  a  way  as  to  give  to  the 
jaw  approximately  the  shape  which  it  had  formerly, 
without  worrying  as  to  its  relations,  since  it  had 
none.  We  shall  pass  in  review  the  different  ap- 
paratus used  for  the  reduction  and  retention  of 
fractures,  made  according  to  a  mould. 

I.  Appliances  with  a  Double  Splint,  for  Teeth 

AND  Chin. 

A.  Description  of  Appliances. 

Bullock's  Appliance. — This  is  a  spHnt  in  vulcanized 
rubber,  moulded  on  to  the  teeth,  which  traverse  it 
in  part  so  as  to  articulate  with  the  upper  teeth.  On 
the  sides  of  the  dental  trough  are  fixed  two  metal  rods, 
which  leave  the  mouth  near  the  commissures,  curve 
downwards,  and  end  in  two  simple  rings  which  serve 
to  fix  them  to  a  chin-plate  by  means  of  a  lace  (Nux). 

Kingsley's  Appliance.*— Little  known  in  France, 
this  has,  however,  been  used  by  CI.  Martin  and 
several  others.  Mahe  has  constituted  himself  an 
ardent  partisan  of  this  appliance,  and  has  expatiated 
on  its  merits  in  his  thesis  devoted  to  the  critical 
study  of  the  treatment  of  fractures  of  the  mandible. f 

*  Kingsley,  "  Treatise  of  Oral  Deformities,"  1882.  See 
also  Hamilton,  "  Practical  Treatise  on  Fractures  and  Dis- 
locations," translated  by  Poinsot,  1884,  p.  135. 

t  G.  Mahe,  "  Critical  Essay  on  the  Treatment  of  Frac- 
tured Mandibles,"  Thdse  Paris,  1900.  See  also,  by  the  same 
author,  "  Concerning  Kingsley 's  Appliance  for  Treatment 
of  Fractured  Mandibles"  {Revue  de  chirurgie,  1897);  and 
"  Note  on  a  Case  of  Complicated  Fracture  of  the  Mandible, 
treated  by  Kingsley 's  Appliance  "  [Rev.  de  chiv.,  1899). 

18 


274 


INJURIES  OF  THE  FACE  AND  JAW 


Kingsley's  arrangement  comprises  a  buccal  trough 
in  vulcanized  rubber,  exactly  fitting  the  teeth  and 
constituting  the  internal  splint.  Two  prolongations, 
formed  of  a  steel  wire,  fixed  to  the  front  of  the  appli- 
ance at  the  level  of  the  canine,  act  as  retention  rods. 
These  prolongations  are  recurved  backwards  slightly 
in  front  of  the  commissures,  and  are  directed  hori- 
zontally as  far  as  the  angle  of  the  jaw,  parallel  to 
the  cheeks.  The  trough  being  constructed  according 
to  a  mould  of  the  dental  arch  which  reproduces  the 


% 


Fig.   129. — Kingsley's  Appliance. 

reduced  fracture,  when  it  is  put  in  place  the  devia- 
tions of  the  fragments  are  found  to  be  corrected. 
It  only  remains  to  maintain  the  appliance  by  taking 
support  from  the  chin,  with  a  submental  dressing 
joining  the  two  prolongations  of  the  trough,  which 
project  on  to  the  cheeks. 

The  dressing  is  done  with  a  linen,  or  better  elastic, 
bandage,  attached  to  each  end  of  the  metal  prolon- 
gations and  supporting  the  chin.  According  to 
Kingsley,  it  is  preferable  to  place  beneath  the 
bandage  an  actual  splint  consisting  of  a  triangular 


KFNGSLEY'S  APPLIANCE  275 

plate,  hollowed  out  behind  for  the  neck,  rounded  in 
front  for  the  chin,  and  extending  each  side  a  little 
beyond  the  jaws. 

For  fractures  with  but  slight  displacement,  it  may 
be  useless  to  keep  the  external  splint  until  the  end 
of  the  consolidation;  the  internal  splint  suffices  after 
a  few  weeks.  In  this  case,  Kingsley,  as  an  improve- 
ment on  his  appliance,  uses  metal  prolongations 
which  are  removable.  To  render  them  so,  it  is  enough 
if,  instead  of  submerging  the  ends  of  the  steel  wires 
in  the  mass  of  vulcanized  rubber,  we  make  these 
same  ends  rectangular  on  section.  Thanks  to  this 
arrangement,  they  will  fit  into  a  metal  sheath  in- 
serted on  either  side  of  the  gutter,  at  the  level  of 
the  commissures.  Thus  modified,  the  appliance  can 
act  as  a  double  splint  at  the  beginning,  and  a  single 
splint  at  the  end,  of  treatment.  Until  late  years, 
this  appliance  (which  has  become  classical  in  the 
United  States)  has  been  employed  in  this  form.* 
On  its  appearance  in  1882,  Kingsley's  appliance 
constituted  an  immense  advance,  and  for  many 
years  it  rendered  excellent  services.  But  it  is  not 
applicable  to  all  cases  of  fracture,  and  has  some 
disabilities  which  invalidate  all  appliances  of  the 
double  splint  type.  We  propose  to  discuss  these 
later  on,  when  we  have  examined  the  general  points 
of  this  type. 

CI.  Martin's  Appliance. — It  consists  of  a  buccal 
piece  and  a  chin-piece,  joined  by  a  fixation  spring. 

I.  Buccal  Piece. — This  is  formed  by  a  double 
trough  of  sheet -steel,  which  has  over  rubber  the 
*   Moriorty,  Boston  Med.  and  Surg.  Journ.,  1897,  p.  509. 


276  INJURIES  OF  THE  FACE  A  AW  JAW 

advantage  of  being  much  more  resistant.  Sheet- 
steel  allows  us  to  use  a  very  thin  piece  (3  mm.). 
This  thickness  of  the  metal  is  so  weak  that,  to  facili- 
tate the  introduction  and  removal  of  the  appliance, 
Martin  uses  two  troughs  exactly  fitting  each  other. 
Only  the  more  superficial  bears  the  fixation  spring. 
This  double  trough,  carefully  plated  to  prevent 
rusting,  should  not  descend  lower  than  the  neck  of 
the  teeth.     It  is  pierced  by  holes  on  its  upper  surface 


Fig.   130. — Appliance  of  CI.  Martin. 

at  points  corresponding  to  the  dental  cusps.  These 
holes  diminish  the  thickness  opposite  the  occluding 
surfaces  of  the  teeth,  and  prevent  undue  elevatioi? 
of  this  surface;  besides,  they  allow  a  strong  curren 
of  water  to  percolate  between  trough  and  teeth,  to 
carry  off  pus  and  food  debris  which  has  passed  in. 
The  trough  takes  in  the  VN^hole  dental  arch,  and 
Martin  insists  on  this  point.  "  A  principle  must  be 
conceded,"  he  says,  "  in  the  treatment  of  fractured 
jaws — namely,  that,  whatever  be  the  fracture,  the 


MARTIN'S  APPLIANCE  277 

buccal  part  of  the  appliance  should  take  its  point 
d'appiii  from  the  whole  dental  arch."* 

2.  Means  of  Fixation  of  the  Buccal  Trough. — ^This 
is  certainly  the  most  interesting  feature  of  Martin's 
contrivance,  t  We  know  that,  in  jaw  fractures 
involving  the  lateral  part  of  the  body  of  the  bone, 
there  occurs  a  displacement,  which  is  constant,  of 
the  fragments,  in  opposite  directions,  by  the  muscles 
inserted    into    their    neighbourhood.     The    anterior 


Fig.    131. — Chin  Trough  of  Martin. 

fragment  is  carried  inwards,  backwards,  and  down- 
wards; the  posterior  fragment  is  carried  especially 
upwards.  To  reduce  the  fracture  and  keep  it  re- 
duced, it  follows  that  the  anterior  fragment  should 
be  lifted  up,  the  posterior  lowered. 

This  last -mentioned  movement  of  lowering  is  all 
the  more  difficult  to  obtain  because  the  track  of  the 

*   Cl.   Martin,    "  The  Treatment  of   Fractured  Mandibles 
by  a  New  Appliance,"  Paris,  1887  (Alcan,  edit.),  p.  10. 
t   Cl.  Martin,  ibid.,  p.  42. 


278  INJURIES  OF  THE  FACE  AND  JAW 

fracture  is  situated  far  back,  and  most  of  the  double 
splint  appliances  act  well  on  the  anterior  fragment, 
but  feebly  on  the  posterior;  for  the  point  d'appui  of 
the  external  splint,  in  the  neighbourhood  of  the  chin, 
is  placed  too  far  forward  relative  to  the  posterior 
fragment.  It  follows  from  this  that  the  most 
posterior  part  of  the  trough  fits  less  tightly  on  the 
teeth  than  the  anterior  part,  although  the  converse  is 
more  necessary  [Translator's  italics].  This  is  the 
reproach  which  can  be  levelled  at  the  appliances  of 


Fig.  132. — Penetrating  Struts. 

Houzelot  and  its  descendants ;  the  same  may  be  said, 
although  to  a  less  extent,  of  Kingsley's. 

In  certain  cases  of  fracture  lying  far  back  these 
splints  give  poor  results,  for  they  succeed  only  partly 
in  achieving  the  depression  of  the  posterior  frag- 
ment. It  may  reasonably  be  laid  down  that  the 
whole  secret  of  the  difficulty  in  treating  fractured 
jaws  lies  in  this  dictum:  Lower  the  posterior  fragment, 
and  keep  it  lowered.  All  other  displacements  are 
easy  to  correct.  To  attain  this  lowering  of  the 
posterior  fragment,  CI.  Martin  avails  himself  of  a 
ringle   spring,    median,    of   steel,    and    fixed   to    the 


MARTIN'S  APPLIANCE  279 

middle  of  the  trough.  In  the  state  of  rest,  the  free 
end  of  this  spring  juts  out  between  the  branches  of 
the  trough.  When  it  is  stretched  and  fixed  by  its 
free  end  under  the  chin,  he  places  the  trough  on  the 
dental  arch,  which  it  covers.  But  its  action  tends 
to  make  itself  felt  especially  on  the  part  of  the 
trough  which  is  farthest  back  in  the  mouth,  precisely 
in  the  region  where  it  is  expedient  to  get  a  forceful 
pressure  to  obtain  the  depression  of  the  posterior 
fragment.  Besides  this,  the  counter-pressure  of  the 
spring  on  the  chin  tends  to  elevate  the  depressed 
anterior  fragment.  The  illustration  (Fig.  130)  made 
by  Martin  shows  clearly  the  action  of  this  spring  so 
ingeniously  arranged. 

3.  Submental  Splint. — Also  of  metal,  this  consists 
of  three  pieces  which  embrace  the  convexity  of  the 
chin  and  the  lower  border  of  the  mandible.  A 
median  piece,  very  narrow,  hts  on  to  the  region  of 
the  symphysis.  It  bears  near  its  posterior  edge  a 
groove  in  which  the  free  extremity  of  the  median 
spring,  fixed  by  a  pressure-screw,  engages.  Laterally, 
this  central  piece  articulates  by  hinges  with  two 
prolongations  which  extend  some  distance  back- 
wards, not  far  from  the  angle  of  the  jaw,  and  which 
embrace  in  their  concavity  the  greater  part  of  the 
margin  of  the  jaw-.  Near  to  their  ends  these  lateral 
wings  bear  hooks;  by  attaching  these  to  laces  we 
transform  this  external  splint  into  a  true  sling  taking 
its  support  from  the  head.  Martin  thus  divided  his 
chin-piece  into  three  articulated  pieces  to  facilitate 
careful  cleansing  in  the  neighbourhood. 

This  apparatus  is  placed  in  position  as   follows: 


28o  INJURIES  OF  THE  FACE  AND  JAW 

The  first  trough  is  apphed  to  the  dental  arcade,  and 
when  all  the  teeth  are  exactly  fitting  the  fracture  is 
found  to  be  accurately  reduced.     The  second  trough, 
carrying  the  retention  spring,  is  then  placed  above 
the  first.     The   end  of  the  spring  is   slid  into  the 
groove  of  the  chin-piece,  and  fixed  by  a  few  turns 
of  the  screw.     Covered  with  gauze  pads  for  its  whole 
extent,  the  chin-piece  is  put  in  place  firmly,  and  its 
lateral  wings  are  kept  up  by  rubber  bands  attached 
to   little   hooks   which   are   supplied   at   their   ends. 
These  elastic  bands  pass  to  the  vertex  of  the  head, 
and,   thus   fixed,   the  whole   appliance  is  embodied 
with  the  jaw;   the  opening  of  the   mouth  is  never 
hampered,    thanks   to   the   elasticity   of   the   rubber 
bands.     To   change   the   gauze   pads,    it   suffices   to 
unhitch  the  hooks  from  the  elastic  bands;  the  lateral 
wings  of  the  chin-piece  fold  back,  whilst  the  median 
part  always  holds  the  end  of  the  spring.     It  is  also 
possible  gently  to  separate  the  median  piece  without 
in  the  least  upsetting  the  reduction  of  the  fracture, 
when  we  wish  to  remove  and  change  the  submental 
pads  soiled  with  pus,  saliva,   or  food  debris.     This 
done,  the  wings  are  drawn  up  and  fixed  anew  to  the 
rubber  bands. 

It  is  also  to  make  more  certain  that  the  fracture 
is  kept  in  a  reduced  position  in  the  various  manoeuvres 
necessitated  for  cleansing  the  apparatus  that  Martin 
advocates  the  use  of  double  troughs  fitted  one  on  to 
the  other. 

Special  Appliances  of  CI.  Martin. — In  a  certain 
number  of  special  cases  Martin  has  been  led  to 
modify  his  appliance.     The  cases  in  question  were 


REIMPLANTATION  OF  A   TOOTH  281 

of  fractures  with  displacements  which  were  unusually 
stubborn  to  correct. 

I.  Troughs  with  Pointed  Penetrating  Struts. — When 
the  margin  of  the  mandible  lacks  teeth  precisely 
in  that  part  (the  posterior  fragment)  which  is  so 
difficult  to  depress,  the  trough  acts  badly  on  the 
latter,  and  tends  to  slide.  This  inconvenience  will 
be  overcome  by  furnishing  the  trough  with  a  sharp 
point  which  passes  through  the  upper  border  of  the 


Fig.    133.- — Metal  Trough.      (Martin.) 

bone.  The  use  of  these  perfectly  tolerated  struts, 
as  by  Martin,  does  not,  according  to  his  observations, 
cause  any  complication. 

2.  Reimplantation  of  a  Recently-lost  Tooth. — When 
a  tooth  comes  out  at  a  point  remote  from  the  seat 
of  fracture,  the  accident  is  not  of  vast  importance. 
It  is  not  so  when  it  occurs  at  the  edge  of  the  fracture 
track.  In  such  a  case  the  loss  of  the  tooth  occa- 
sionally determines  an  actual  loss  of  substance,  for 
the  fragments   tend  to  approach  each  other  to  fill 


282  INJURIES  OF  THE  FACE  AND  JAW 

the  chasm  produced.  Therefore  we  should  never 
extract  a  tooth,  even  if  tottering,  when  it  is  in  relation 
to  the  fracture  track.  [This  point  has  been  much  in 
debate  in  England.  Personally,  I  have  several  times 
seen  a  tooth,  which  was  actually  rocking  in  the  line 
of  fracture,  become  firm,  and  thereafter  be  most 
useful  for  fixing  an  appliance. — Tr.]  Maybe  it  will 
fall  out  later;  but  its  presence  during  the  first  weeks 
of  consolidation  will  at  least  have  prevented  a 
deformity  due  to  approximation  of  the  fragments. 


Fig.   134. — Trough.      (^lartin.) 

If  the  trauma  responsible  for  the  fracture  has 
entailed  simultaneously  the  loss  of  a  tooth  im- 
mediately abutting  on  the  fracture  track,  CI.  Martin 
advises  that  a  cone  of  tin  of  the  same  shape,  soldered 
to  the  trough,  be  inserted  into  the  socket,  and  left 
there  until  the  fracture  is  entirely  consolidated. 

3.  Jnterdental  Screws  (Fig.  134). — In  certain  re- 
fractory cases  Martin  has  used,  so  as  better  to  im- 
mobilize the  trough,  screws  fixed  to  this  latter,  and 
passing   through   the    intervals   between   the   teeth. 


SEPARATION  OF  FRAGMENTS 


283 


This  exceptional  resource  should  only  be  employed 
for  a  few  days,  since  it  damages  the  teeth. 

4.  Appliance  to  correct  Overlapping. — In  cases  of 
fractures  beginning  to  consolidate  with  overlapping 
of  the  fragments,  Martin  recommends  the  arrange- 
ment seen  in  Fig.  135.  The  gradual  pressure  of 
the  screw  stretches  the  adhesions,  and  replaces  the 
fragments  in  good  position. 


Fig.    135. — Martin's  Trough,  with  a  Screw  to  complete  the 

Reduction. 


.  5.  Separation  of  the  Lower  Margins  of  the  Frag- 
ments.— In  simultaneous  fractures  of  the  condylar 
neck  and  the  body,  Martin  has  described  a  peculiar 
flattening  of  the  face,  due  to  the  inward  displacement 
of  the  middle  fragment.  In  such  a  case,  the  buccal 
trough  keeps  the  upper  margin  of  this  fragment  well 
enough  in  place;  but  its  lower  edge,  without  any 
internal  support,  persists  in  being  carried  inwards 


2  84  INJURIES  OF  THE  FACE  AND  JAW 

To  correct  this  displacement  (for  that  matter,  a  very 
rare  one),  Martin  has  successfully  used  his  appliance, 
but  replacing  the  chin-piece  by  a  rubber  ball  (Fig. 
136). 

"  This  ball,  thanks  to  its  shape,  depresses  the  soft 
parts  below  the  chin,  and  preserves  the  form  of  the 
lower  border  of  the  bone  if  its  arch  tends  to  flatten 
out.  The  pressure  of  the  ball  may  in  the  long-run 
ulcerate  the  skin  where  it  presses.  So  that  we  should 
not   leave   it   for   longer   than   is   necessary   for   the 


Fig.    136. — Martin's   Appliance  with  Rubber  Ball. 

formation  of  adhesions.  Then  it  is  to  be  replaced 
by  an  ordinary  appliance.  We  add  the  rubber  ball 
to  the  end  of  the  spring  by  perforating  the  ball 
through  and  through  with  a  knife  which  has  been 
moistened  to  make  it  cut  rubber.  It  only  remains 
to  push  the  spring  through  the  tunnel  cut  in  the 
ball,  which  is  in  this  way  firmly  fixed." 

Construction  of  Martin's  Appliance. — We  have  seen 
that  the  metal  employed  was  sheet  steel  0'3  mm- 
thick.  Once  the  arch  is  moulded,  and  after  its  cor- 
rection, we  cast  a  second  mould  of    it  in  zinc,  with 


CONSTRUCT rXG  MARTIX'S  APPLIANCE        283 

matrix  of  lead,  which  will  serve  for  stamping  the 
sheet -steel;  of  this  we  make  the  dental  trough.  The 
method  employed  does  not  differ  from  that  in  current 
use  for  ordinary  dental  prosthesis.  It  is  as  well 
to  make  the  steel  immune  to  changes  by  contact 
with  buccal  fluids,  by  plunging  it  into  a  bath  of 
molten  tin  (after  washing  it  in  water  to  which  a  few 
drops  of  sulphuric  acid  have  been  added).  Despite 
its  simple  appearance,  Martin's  appliance  is  difficult 
to  make,  for  sheet-steel  is  really  not  convenient  for 
stamping.  As  for  the  rest  of  the  process,  we  must 
give  the  spring  a  suitable  curve  so  that  it  shall  not 
have  an  irregular  actiom  This  precise  regulation  of 
the  spring  presents  certain  difficulties.  In  order 
that  the  spring  should  act  uniformly  and  effectively, 
the  pressure  made  by  it  should  be  distributed  uni- 
formly over  the  whole  surface  embraced  by  the 
intrabuccal  trough ;  and  it  should  be  counterbalanced 
by  the  point  d'appiii  which  the  spring  takes  from  the 
chin.  The  difficulty  lies  in  accurately  reckoning  the 
curve  which  the  spring  should  take;  for  if  this  curve 
be  miscalculated,  the  pressure  will  be  felt  unduly 
either  by  the  posterior  or  the  anterior  part  of  the 
appliance,  which  will  interfere  with  the  retention  of 
the  fragments.  The  problem  is  exactly  to  hit  off 
the  pressure  to  use,  and  has  nothing  to  do  with  the 
construction  of  the  appliance.  Martin  has  shown 
the  way  to  solve  it.  This  consists  of  the  application 
of  a  provisional  chin-piece  without  mortise  or  hooks. 
Beneath  this  we  slide  a  second  plate  which  has 
mortise  and  hooks  ;  and  so  the  spring  is  easily 
fixed. 


286  INJURIES  OF  THE  FACE  AND  JAW 

Modification  of  Martin's  Appliance. — The  difficulty 
in  stamping  the  dental  trough  in  sheet-steel  led 
Martin  to  alter  his  appliance  so  as  to  make  its  con- 
struction easier.  He  suggests  the  use  of  a  double, 
coarser  trough,  similar  to  an  impression  tray,  but 
always  in  sheet -steel.  The  superficial  trough  carries 
the  spring,  and  the  underlying  one  is  filled  with  a 
malleable  substance  such  as  gutta-percha.  In  taking 
the  impression  of  the  arch  (restored  to  its  form)  by 
this  method,  we  get  a  buccal  trough  just  as  exact 
as  the  metal  one,  and  answering  the  same  purpose. 
CI.  Martin  remarked  that:  "  The  use  of  gutta-percha 
is  not  a  reversion  to  the  appliance  of  Morel-Lavallee ; 
for  not  onl}'  is  this  substance  contained  in  a  metal 
gutter  which  prevents  a  quick  alteration  of  shape, 
but  also  the  impression  is  given  by  a  dental  arch  of 
which  the  shape  is  restored."*  This  gutta-percha 
trough  has  the  drawback  that  it  takes  up  more  room 
in  the  mouth  than  the  stamped  trough,  and  in  time 
its  shape  changes.  We  remedy  this  latter  fault 
easily  by  making  a  new  impression  in  the  gutta, 
resoftened  by  heat.  Martin  has  also  proposed  to 
use  silver  amalgam  to  take  the  impression,  instead 
of  gutta-percha.  It  seems  that  we  might  equally 
well  employ  godiva.  In  any  case,  "  whatever 
be  the  material  used,"  says  Martin,  "  we  must 
bear  in  mind  that  it  should  never,  under  pain  of 
starting  inflammation  in  the  gums,  touch  them; 
this  is  an  axiom  from  which  we  must  never 
diverge." 

*  Martin,  "The  Treatment  of  Fractured  Mandibles  by  a 
New  Appliance,"  Paris,  1887  (Alcan,  edit.),  pp.  72,  76. 


MARTINIER'S  APPLIANCE 


^07 


.  Martinier's  Appliance.* — Struck  by  the  difficulties 
in  making  Martin's  apparatus  in  a  case  where  the 
latter  had  not  given  him  the  expected  results,  one 
of  us  has  made  and  applied  with  success  an  appliance, 
also  with  two  splints,  and  constituted  as  follows : 

I.  Mouth-Splint. — This  is  a  stamped  double  trough 
fitting  on  to  the  restored  dental  arch.  It  is  made 
of  dental  alloy,  a  metal  easy  to  work  on,  while  offering 
at  the  same  time  great  resistance.  Two  extrabuccal 
prolongations    are    soldered    to    the    upper    trough. 


Fig.   137. — Martinier's  Appliance. 


These    prolongations    are    pierced    at    their    end    by 
holes  for  the  passage  of  screws. 

2.  Chin-Splint. — This  is  of  aluminium.  It  can  be 
divided  into  three  parts — one  central  and  two  lateral 
— which  are  either  like  the  submental  plate  of  Martin, 
or  are  in  two  parts  separated  by  a  transverse  line 

*  Martinier,  "  A  Case  of  Fractured  Mandible:  Retention 
Appliance  "  [Odontol.,  Mai,  1892).  "  Complicated  Fracture 
of  the  Mandible  "  {Odontol.,  Fevr.,  1893).  "  Considerations 
on  Two  Cases  of  Fractured  ^Mandible  "  [Odontol.,  Janv,, 
1895)  • — Paul  Dubois,  1894,  "  Affections  of  the  Teeth, 
Mouth,  and  Jaws,"  p.  552. 


288  INJURIES  OF  THE  FACE  AND  JAW 

directed  obliquely  under  the  chin,  and  joined  by  two 
hinges  placed  at  their  ends.  The  junction  of  the 
two  parts  is  made  safe  by  a  latch-fastening  situated 
in  front.  The  submental  plate  carries  two  parallel 
metal  prolongations  placed  laterally  at  the  labial 
commissures,  which  are  tapped  with  a  screw-thread 
and  intended  for  the  insertion  of  the  screws  which 
join  this  submental  part  to  the  buccal  trough.  The 
submental  splint  is  attached  to  a  skull-cap  with 
rubber  bands  inserted  towards  the  back  of  the 
plate  by  means  of  holes  previously  pierced  for  this 
purpose. 

3.  Means  of  Retention. — This  is  achieved  by  the 
screws  joining  the  buccal  trough  on  to  the  submental 
splint,  and  inserted  into  {a)  the  lateral  extensions 
soldered  on  to  the  buccal  trough  opposite  the  canines, 
and  {b)  the  metal  extensions  fixed  to  the  submental 
plate,  immediately  below  the  former.  The  nuts 
fixed  to  the  ends  of  these  screws  enable  us  to  be 
certain  of  correcting  the  vertical  displacements, 
according  to  how  much  one  or  both  nuts  are  tight- 
ened. The  position  occupied  by  the  extensions  and 
by  the  screws  (between  the  canine  and  first  bicuspids) 
gives  them  the  advantage  of  a  powerful  leverage  on 
the  posterior  fragments,  all  the  while  keeping  these, 
or  the  anterior  fragments,  rigidly  in  place. 

Delair*s  Appliance.* — This  has  many  analogies  to 

*  Delair,  "  Simplified  Appliance  for  Fractures  of  the 
Mandible"  [Odontologie,  15  Fevr.,  1906,  p.  97).  See  also 
Couturier,  "  Observations  on  a  Fracture  of  the  Mandible: 
Application  of  Delair's  Apphance  in  the  Army  "  {Odontologie, 
15  Dec,  1907,  p.  406). 


DEL  AIR'S  APPLIANCE 


289 


that  of  Martinier.     It  consists  of  the  following  three 
pieces : 

I.  Buccal  Splint. — For  its  construction,  the  author 
discards  stamped  metal  and  uses  cast  tin.  The  use 
of  this  metal  partly  constitutes  the  originality  of  the 
appliance.  The  construction  of  such  a  trough  is  in 
fact  very  easy  and  rapid;  for  it  suffices  to  adjust  and 
correct  the  dental  arch,  and  then  pour  a  mass  of 


Fig.   138. — Simple  Appliance  of  Delair  for  Fracture  of  the 

Lower  Jaw. 

lead  into  the  mould  of  this  arch.  However,  Delair 
advises,  in  order  to  obtain  a  more  resistant  substance, 
the  employment  of  a  mixture  of  three  parts  of  plaster 
with  one  part  of  kaolin  and  fire-clay  in  equal  pro- 
portions. This  gutter  presents  in  front  two  exten- 
sions, also  of  tin.  To  obtain  the  cast  of  this  in  a 
single  piece,  the  author  proceeds  in  the  following 
way: 

On  the  plaster  impression  he  superposes  two  plates 

19 


290 


INJURIES  OF  THE  FACE  AND  JAW 


of  pink  wax,  which  he  cuts  off  to  within  6  mm.  of 
the  neck  of  the  teeth.  In  front,  between  each  canine 
and  second  bicuspid,  he  adds  some  small  bars  of 
wax  4  cm.  long  and  15  mm.  wide;  these  are  made  of 


Fig.   139. — Dclair's  Simplified  Appliance  for  Fractures. 

three  thicknesses,  cut  out  of  a  plate  of  rose-coloured 
wax.  The  whole  is  invested  in  plaster  as  in  an 
ordinary   flask.     The  second  part   of  the  mould  is 


DELAIR'S  APPLIANCE  291 

taken  with  composite  plaster,  or  even  with  casting- 
sand.  The  wax  is  removed  and  we  proceed  with 
the  casting.  To  make  this  easier,  the  author  ad- 
vises that  we  place  on  the  first  flask  "  the  upper  half 
of  another,  which  we  turn  upside  down  without  the 
interposition  of  a  cover,  to  get  during  the  melting 
process  what  we  call  (in  metal-workers'  parlance) 
the  '  runner  '  or  heavy  mass.  This  enables  the  tin 
to  melt  into  the  smallest  crannies  of  the  mould. 
We  must  carefully  dry  the  mould  before  casting  the 
tin  at  a  dull  red  heat;  fifteen  minutes  later  we  take 
it  out  of  the  mould,  finish  the  piece  with  a  file,  and 
polish  as  required  "  (Delair). 

2.  Chin-Splint. — This  is  of  aluminium,  cut  out  of 
a  plate  i  mm.  thick,  and  shaped  by  a  horn  or  box- 
wood mallet. 

3.  Means  of  Retention. — This  is  a  U-shaped  piece 
cut  out  of  a  plate  of  German  silver  1*5  mm.  thick, 
whose  ends  are  slit  along  each  limb  of  the  U.  This 
piece  is  riveted  to  the  chin-piece  in  the  mid-line, 
and  the  two  branches  are  curved  vertically  upwards. 
A  screw  is  placed  at  the  end  of  each  of  the  extensions 
of  the  tin  gutter,  these  ends  being  bent  downwards. 
These  screws  engage  in  the  grooves  cut  in  the  vertical 
branches  of  the  chin-piece,  and  receive  winged  nuts 
which  allow  us  to  fix  the  retention  branches  and  to 
approximate  the  two  splints  at  will.  This  very 
simple  appliance  can  be  made  quickly,  and  Delair 
remarks  that  it  can  be  turned  out  in  two  hours 
without  any  special  outfit. 


292  INJURIES  OF  THE  FACE  AND  JAW 

B.  Critical  Review  of  Double  Splint  Appliances  made 
according  to  a  Corrected  Mould  of  the  Dental 
Arch. 

We  have  already  said  that  the  difficulty  of  treating 
fractures  of  the  lower  jaw  lies  in  correcting  the  dis- 
placement of  the  fragments.  Fractures  in  or  near 
the  middle  line  present  but  little  displacement,  and, 
when  it  exists,  it  is  very  easy  to  correct.  In  favour- 
able cases  any  of  the  appliances  give  good  results. 
But  when  there  is  a  double  fracture,  as,  for  instance, 
at  each  mental  foramen,  the  displacement  of  the 
median  fragment  is  enormous,  for  this  latter  swings 
downwards  and  backwards.  .In  the  same  way,  when 
the  fracture  passes  through  the  lateral  part  of  the 
body  of  the  bone,  the  posterior  fragment  is  elevated, 
while  the  anterior  is  depressed  and  carried  inwards 
and  backwards.  The  correction  of  such  displace- 
ments become  very  difficult,  and  in  like  cases  any 
appliance  whatever  will  only  give  poor  results. 

In  the  case  of  fracture  into  three  fragments,  notably 
when  the  middle  fragment  abuts  on  the  mid-line, 
any  of  the  appliances  with  double  splints  bearing  a 
chin -piece  which  closely  hugs  the  border  of  the  jaw 
will  easily  lift  the  middle  fragment.  x\nd  the  lateral 
fragment  will  be  lowered  as  long  as  the  fractures  do 
not  lie  too  far  back.  When  the  fracture  passes  very 
far  back — for  instance,  just  in  front  of  the  wisdom 
tooth — it  becomes  very  difficult  to  lower  the  posterior 
fragment,  because  it  is  only  by  the  end  of  the  dental 
splint  that  we  can  act  on  it. 

It  appears,  then,  that  Martin's  is  the  best  of  the 


REMARKS  ON  DOUBLE  SPLINTS  293 

double  splint  appliances;  its  weak  point  is,  par- 
ticularly, its  difficulty  of  construction,  for  it  requires 
sheet-steel.  This  is  not  a  real  inconvenience  except 
in  so  far  as  it  concerns  the  sort  of  metal  chosen  by 
Martin.  Sheet-steel  is  in  truth  difficult  for  stamping. 
But  if  we  substitute  an  alloy  of  silver  and  platinum 
for  the  buccal  trough,  and  aluminium  for  the  chin 
piece,  the  obstacle  disappears;  when  we  make  the 
chin-piece  of  stamped  aluminium,  we  beat  out  or 
stamp  hinges  for  the  joints,  and  in  this  case  tlie 
mortises  are  riveted.  But  there  is  above  all  the 
irregular  action  of  the  spring,  due  to  the  difficulty 
encountered  in  giving  it  the  curve.  In  order  for  its 
action  to  be  effective,  we  must  succeed  in  giving  it 
such  a  curve  that  the  pressure  it  exercises  may  be 
distributed  on  a  plane  parallel  to  the  surface.  And 
we  have  mentioned  the  difficulties,  which  were  for 
that  matter  recognized  by  Martin,  who  showed  a 
means  (already  cited  by  us)  of  remedying  them.  We 
must  add  that  this  spring  is  generally  made  of  a 
clock  spring,  and  is  not  always  sufficiently  powerful. 
This,  again,  is  a  serious  inconvenience. 

Kingsley's  appliance  in  vulcanized  rubber  seems 
to  be  free  from  this  disadvantage.  But  its  incon- 
veniences are  numerous.  It  is  poorly  tolerated  by 
the  patient,  for  the  metal  branches  which  pass  along 
the  cheeks  interfere  with  a  lateral  decubitus.  They 
prevent  the  man  from  bending  his  head  sideways 
without  pain.  The  removable  metal  branches  do 
away  with  this  inconvenience  at  the  end  of  a  few 
days.  The  metal  branches  have  also  other  draw- 
backs.    Their  shape,  curve,  and  situation,  make  the 


294  INJURIES  OF  THE  FACE  AND  JAW 

appliance  difficult  to  construct.  They  have  to  be 
made  of  steel  wire  strong  and  rigid  enough  to  bear, 
without  weakening,  the  tension  of  rubber  or  bandage 
which  joins  them  to  the  submental  splint.  It  follows 
that  their  curve  (at  the  level  of  the  labial  com- 
missure), and  the  horizontal  distance  between  them 
(they  must  be  exactly  parallel)  along  the  cheeks, 
are  not  easy  matters  to  bring  about.  We  lack  any 
precise  indications,  and  the  result  of  any  defects 
may  be  pressure  on  neighbouring  parts.  In  this  case 
the  modifications  to  which  we  must  subject  them 
entail  manoeuvres  which  are  distressing  to  the 
patient. 

The  intrabuccal  trough,  which  is  made  of  rubber, 
is  thick  and  bulky.  The  lateral  pull  which  it  under- 
goes, when  we  fix  the  appliance  to  the  metal  rods 
to  join  it  on  to  the  chin-piece,  results  in  the  thicken- 
ing of  the  gutter,  especially  in  its  middle  part.  This 
adds  to  the  bulk  of  the  appliance  still  more,  and 
may  cause  irritation,  sometimes  very  badly  borne  by 
certain  intolerant  patients.  The  stability  of  the 
apparatus  leaves  much  to  be  desired,  and  exacts  a 
continuous  watchfulness.  The  chin-piece,  attached 
either  by  straps  of  webbing  or  by  rubber  bands  to 
the  metal  rods,  slips  forwards.  The  elasticity  of  the 
material  used  for  the  straps  obviously  distributes 
the  pressure  uniformly;  but  its  lack  of  rigidity  is 
a  defect,  and  we  may  accuse  it  of  pressing  laterally 
on  the  mandible,  and  of  throwing  the  chin-piece 
forwards,  owing  to  alterations  in  the  obliquity  of 
the  straps.  All  who  have  applied  Kingsley's  appli- 
ance have  been  able  to  note  this  disadvantage,  which 


REMARKS  ON  DOUBLE  SPLINTS 


295 


has  long  since  been  pointed  out  by  Martin.  The 
figures  will  readily  make  comprehensible  the  criticisms 
levelled  against  this  appliance. 

Fig.  140  is  the  scheme  of  the  Kingsley  appliance 
viewed  from  in  front.     We  notice  that  the  edges  of 


Fig.  141. 


Fig.   142.  Fig.    143. 

Figs.   140  to  143. — Scheme  of  Kingsley's  Appliance. 
(Mar  tinier.) 

the  stretched  linen  bandage  bound  a  trapezoid 
space  ABCD,  the  fixed  points  being  A  and  D.  The 
forces  acting  along  AB  and  DC  are  thus  not  per- 
pendicular to  the  plate.  They  may  be  resolved 
(Fig.   141)  into  vertical  components,   and  also  into 


296  INJURIES  OF  THE  FACE  AND  JAW 

horizontal  components  BC  and  CB.  The  effect  of 
the  latter  is  to  approximate  the  points  B  and  C — 
that  is,  to  squeeze  the  jaw. 

Fig.  142  is  the  scheme  of  the  same  appliance  seen 
from  the  side.  Here  again  the  edges  of  the  bandage 
form  a  trapezoid,  ABCD,  the  points  of  fixed  attach- 
ment being  the  whole  length  of  AD.  The  force 
applied  at  D  is  practically  at  right  angles  to  the  plate. 
But  when  we  pass  from  D  towards  A,  the  forces  are 
transmitted  obliquely  along  BC;  and  they  have  a 
horizontal  component  from  behind  forwards,  tending 
to  throw  the  plate  forwards.  We  should  add  that 
the  linen  bandage  is  not  absolutely  fixed  to  the  metal 
extensions — they  can  slide;  and  this  being  so,  there 
is  nothing  to  hold  either  fracture  or  dressing. 

Martinier's  Appliance. — In  this  the  action  of  the 
spring  on  the  posterior  fragments  may  be  insufficient. 
It  was  as  the  result  of  a  failure  of  this  sort  that 
Martinier  had  (for  a  case  of  double  fracture  with 
considerable  displacement)  to  replace  the  spring  by 
screws  working  on  the  trough  and  the  submental 
part  of  the  appliance.  This  appliance  finds  its  chief 
indication  when  it  is  laborious  to  maintain  the  re- 
duction, and  in  which  the  fragments  tend  to  be 
refractory  to  replacement.  The  mechanical  con- 
ditions of  the  forces  apphed  are  quite  different  from 
the  preceding  appliances,  and  in  theory  their  applica- 
tion appears  to  be  better.  Fig.  144  is  a  reproduction 
of  this  appliance.  The  screws  are  vertical;  the  metal 
prolongations  through  which  they  pass  are  horizontal. 
Thus,  each  screw  forms  with  the  extensions  a  rigid 
rectangle,  and  the  forces  applied  to  this  fixed  system 


MA  R  TINIER '  S  A  PPL  I A  NCE 


igj 


are  vertical  and  diametrically  opposed  (Fig.  144). 
Therefore  they  balance  each  other. 

Disadvantages:  The  position  of  the  prolongations 
at  the  labial  commissures  facihtates  the  flow  of 
saliva,  and  necessitates  the  frequent  changing  of 
the  submental  dressing.  The  tightening  of  the  nuts 
on  the  screws  must  be  done  with  great  care,  so  as  to 
put  on  the  two  screws  a  scrupulously  equal  pressure. 

Martinier's  appliance  is  easy  enough  to  make,  and 


Z} 


Fig.   i_i4. — Martinier's  Appliance  and  its  Scheme. 

the  metal  buccal  trough  is  only  slightly  irksome, 
because  it  lifts  up  the  interdental  articulation  as 
little  as  possible. 

Delair's  appliance  is  retained  by  a  method  which 
appears  similar  to  the  preceding  (Martinier's).  It 
has  the  advantage  of  extreme  rapidity  of  construc- 
tion. But  as  a  set-off  one  can  make  the  following 
criticisms : 

I.  The  tin  trough  has  the  same  disadvantages  as 
those  already  quoted  apropos  of  Kingsley's  apparatus 
and  thick  troughs. 


29S  INJURIES  OF  THE  FACE  AND  JAW 

2.  So  as  not  unduly  to  raise  the  articulation,  and 
to  allow  the  patient  to  shut  his  mouth,  we  are  com- 
pelled to  diminish  sensibly  the  thickness  of  the  tin 
trough  at  its  ends.  If  we  are  dealing  with  a  case  of 
fracture  in  which  the  posterior  fragment  is  difficult 
to  depress,  the  tin  splint  will  have  to  be  thinned  as 
much  as  possible,  and  so  will  offer  the  minimum  of 
resistance,  exactly  at  the  spot  where  it  ought  to  pro- 
vide most  rigidity.  Now  tin,  essentially  malleable, 
ohers  no  resistance  when  below  a  certain  thickness. 
A  trough  stamped  like  that  of  Martinier  would  be 
more  logical,  and  assure  the  best  chances  of  acting 
on  the  posterior  fragment. 

3.  The  two  vertical  branches  of  the  retention- 
piece,  which  join  the  two  splints  (buccal  and  chin) 
between  them,  are  a  little  too  near  the  mid-hne. 
The  pressure  works  well  in  front.  But  its  action  is 
less  effective  at  the  ends  of  the  buccal  trough,  and 
the  maintenance  of  the  posterior  fragment  suffers 
from  this. 

II.  Appliance  consisting  of  a  Double  Dental 
Splint,  Lower  and  Upper. 

Gunning's  Appliance.* — Gunning  has  described 
several  different  appliances,  of  which  one,  which 
takes  its  point  d'appui  from  the  upper  jaw,  has 
remained  classical  under  his  name.  The  appliance 
of  Gunning,  properly  so  called,  consists  of  two  gutters 

=^  Gunning,  "  Treatment  of  Fracture  of  the  Jaw  "  {In- 
depcndant  Pratic.  Bui.,  18S0,  i.  171;  ii.  296,  367,  430,  468, 
526,  564.  See  also  Garretson,  "  A  System  of  Oral  Surgery," 
1873). 


GUNNING'S  APPLIANCE  299 

of  vulcanized  rubber  (one  fitting  the  upper,  the  other 
the  lower  dental  arch),  made  of  course  to  a  corrected 
mould.  These  two  splints  or  troughs  are  opposed, 
and  united  on  four  pillars,  which  thus  make  between 
them  three  windows  5  or  6  mm.  high.  When  in 
place,  the  two  arches  fit  into  the  two  splints,  and  the 
lower  jaw  is  further  immobilized  by  a  bandage  or 
sling.  In  other  words,  the  lower  jaw  is  compelled 
to  be  immobile  by  taking  the  upper  jaw  as  a  splint, 
but    with    the    interposition    of    two    troughs.     The 

J  III  ill    ,:i    .i\   k  \ 


Fig.   145. — Gunning's    Appliance.      (Dubois.) 

windows  which  separate  the  troughs  allow  Uquid 
food  to  be  introduced  more  easily. 

In  spite  of  its  apparent  simplicity.  Gunning's 
apparatus  is  not  easy  to  make,  because  it  must  be 
fitted  with  extreme  precision,  and,  in  fact,  one 
requires  to  have  constructed  one  of  these  appliances 
to  make  a  fair  estimate  of  them. 

Placing  it  in  position  in  the  mouth  also  presents 
some  difficulties.  First  one  must  fit  the  appliance 
on  to  the  upper  jaw,  so  as  to  make  the  lower  arch 
penetrate  into  the  corresponding  trough  and  so 
reduce  the  displaced  fragments.  Finally  a  bandage, 
firmly  put  on,   and  preferably  of  elastic,  keeps  the 


300  INJURIES  OF  THE  FACE  AND  JAW 

fragments  in  the  trough  and  resists  their  displace- 
ment. 

The  great  fault  of  Gunning's  appliance  is  its  bulk 
and  the  necessity  to  immobilize  the  temporo-maxillary 
joint.  It  is,  then,  an  irksome  contrivance  which  will 
not  always  be  tamely  endured  by  all  patients.  Never- 
theless it  has  one  advantage — that  it  immobilizes  the 
jaw  while  keeping  the  mouth  open.  And  we  shall  see 
later  that  to  open  the  mouth  in  cases  of  fracture 
encourages  the  depression  of  the  posterior,  and  the 
elevation  of  the  anterior,  fragment,  and  therefore 
the  correction  of  the  displacement.  Despite  its  in- 
conveniences, Gunning's  splint  can  give  good  results 
in  certain  cases  of  multiple  fractures.  Like  that  of 
Kingsley,  it  is  in  frequent  use  in  the  United  States. 

III.  Appliances  with  a  Simple  Dental  Splint. 

These  consist  of  a  splint  made  to  a  corrected  mould, 
and  embracing  as  closely  as  possible  the  contours 
of  the  dental  arch.  Fauchard  had  already  made 
similar  splints  with  sheets  of  lead.  The  appliance 
of  Nicolle  of  Neubourg,  and  that  of  Malgaigne,  were 
formed  by  two  sheets  of  iron  applied,  one  on  the 
inside,  the  other  on  the  outside,  of  the  dental  arch, 
and  joined  one  to  the  other  by  screws  passing  between 
the  teeth.  But  these  appliances  were  not  made  to 
a  corrected  mould.  It  is  in  Hammond's  splint  that 
we  see  the  appearance  of  the  true  type  of  dental 
splint  made  after  taking  an  impression. 

Hammond's  Appliance.* — It  consists  of  a  strong 

^  Christopher    Heath,     "  Diseases    and    Injuries    of    the 
Jaws,"  translat.  Darin,  London  and  Paris,  p.  40. 


HA  MMOND ' S  SPLINT 


?oi 


metal  wire,  bent  by  pincers  to  follow  the  contour 
of  the  arch  at  the  level  of  the  necks  of  the  teeth, 
on  the  buccal  and  the  vestibular  aspects.  This 
splint  may  be  compared  to  a  well-adjusted  frame- 
work around  the  lower  dental  system,  held  in  place 
by  a  certain  number  of  ligatures  passed  through  the 
interdental  spaces  (Fig.  146). 


F— - 


Fig.    146. — Hammond's    Splint.      (Heath. 
I,  Framework;  ABCDEF,  fixation  loops. 


Dental  Troughs  or  Gutters. — These  are  legion,  and 
we  cannot  here  enumerate  all  the  writers  who  have 
made  use  of  them.  They  conform  to  type  as  a  rule, 
and  may  be  sometimes  in  stamped  or  cast  metal, 
sometimes  in  vulcanized  rubber.  According  to  the 
researches  of  Mahe,  it  appears  that  the  tirst  metal 
trough  was  applied  by  Tanes  in  London,  and  the 
first  rubber  trough  by  Sand  in  New  York,  in  i860. 

The  type  of  trough  or  gutter  varies  above  all  with 


302  INJURIES  OF  THE  FACE  AND  JAW 

the  substance  used  and  the  means  of  retention. 
Those  of  vulcanized  rubber  have  the  defect  of  being 
thick  and  bulky,  and  thus  irksome  to  the  patient. 
Metal  troughs,  being  much  thinner,  are  better  sup- 
ported (see  Fig.  147).  Martinier  recommends  dental 
alloy,  other  writers  German  silver,  Dubois  and  Billet 
aluminium.  CI.  Martin  sheet-steel. 


Fig.   147. — Metal  Dental  Splint. 


(Martinier.) 


At  the  present  time,  with  the  facilities  which  have 
been  given  to  dentists  in  casting  metals  under  pres- 
sure, there  is  no  point  in  discussing  which  is  the 
metal  of  choice.  Cast  dental  alloy,  cast  silver,,  or 
better  cast  aluminium,  pure,  allows  us  to  make  in 
a  very  short  time  a  metal  gutter  of  an  enduring 
soUdity  and  rigidity  with  a  very  small  bulk.  These 
troughs  are  pierced  by  holes,  allowing  a  strong 
current  of  water  to  cleanse  the  underlying  dental 
arch  after  the  trough  has  been  fitted.    They  are 


DENTAL  TROUGHS  303 

kept  in  place  either  by  ligatures  passed  between  the 
teeth  and  through  the  holes  pierced  in  the  metal, 
or  by  wedges,  or  even  by  screws  (Martin).  They 
should  not  descend  lower  than  the  necks  of  the 
teeth,  and  should  extend  the  whole  length  of  the 
arch. 

Martin*  has  recommended  in  certain  cases  a  splint 
which  resembles   both  a  trough   and  a   Hammond 


© 


/^.,^^''^ 


/  i 


/■/[ 

■'   i 
.  { 


/ 


Fig.    148. — Three-Wire  Splint  of  Martin. 

splint.  It  consists  of  an  arrangement  of  three  silver 
wires  joined  together  at  three  or  four  points.  Two 
of  these  wires  are  arranged  as  in  a  Hammond  splint ; 
the  third  is  placed  on  the  cutting  edge  of  the  teeth. 
This  appliance  is  fitted  by  interdental  ligatures  of 
silk  or  wire. 

*  Martin,    "  Treatment  of  Fractures   of  the   Mandible," 
Paris,  1887,  p.  76;  Alcan,  edit. 


304  INJURIES  OF  THE  FACE  AND  JAW 

Lastly,  of  late  years  an  excellent  retention  method 
— certainly  superior  to  all  others — has  been  in  use. 
We  refer  to  the  sealing  of  a  trough  with  cement ;  for 
our  part,  we  have  used  this  for  a  long  time. 


Criticisms  of  Appliances  consisting  of  a  Single  Splint. 

The  appliances  reduced  to  a  simple  dental  splint 
are  certainly  the  most  attractive.     When  they  are 
well  made,  exactly  fitted  and  well  placed,  they  give 
remarkable  results;  the  invalids  can  eat,  talk,  make 
use  of  their  jaws  without  any  pain  or  worry.     The 
appHance,  if  reduced  to  a  minimum,  is  not  visible, 
and   its   application   is    followed   by   an    immediate 
functional  restoration.     There  is  one  sine  qua  non  of 
success — the  absolute  fixation  of  the  splint.     Ham- 
mond's appliance  has  the  fault  of  reducing  the  up- 
and-down  displacements  imperfectly;  it  is,  in  fact, 
formed  by  an  open  cage,  and  in  that  direction  exer- 
cises but  a  feeble  action.     Martin's  appliance  with 
three   wires   fulfils   this  task.     Troughs  formed  out 
of  a  stamped  metal  plate  are  certainly  superior  to 
the  splints  formed  by  coupled  wires,  for  they  adapt 
themselves  better  to  the  dental  arch  and  act  on  its 
whole  surface. 

But  ligatures  are  only  a  mediocre  method  of  reten 
tion,  for  they  can  never  give  to  the  appliance  an 
absolute  fixation.  Thus,  it  happens  that  indications 
for  the  use  of  the  simple  trough  have  for  a  long  time 
been  narrowed  down  to  feeble  displacements  easy  of 
correction,  fractures  of  the  anterior  part  of  the  body 
of  the  jaw.     When  we  wish  to  use  it  to  maintain 


TROUGHS  305 

the  reduction  of  double  fractures  with  great  dis- 
placement, or  of  fractures  abutting  on  the  wisdom 
tooth,  where  the  posterior  fragment  is  drawn  up 
and  difficult  to  keep  depressed,  the  simple  trough 
fails  utterly,  and  we  are  compelled  to  have  recourse 
to  double  splint  appliances.  Nevertheless  it  is  not 
the  trough  which  should  be  blamed,  but  its  mode 
of  retention,  which  will  not  assure  a  sufficient  fixation. 

Sealed  on  to  the  teeth  with  dental  cement  like  an 
ordinary  bridgework,  the  trough  becomes  a  perfect 
mode  of  treatment  for  fractures  of  the  body  of  the 
lower  jaw.  For  ten  years  one  of  us  has  used  this 
method  of  treatment,  in  fourteen  cases  of  fractures, 
most  of  them  under  the  care  of  his  professor,  M. 
Sebileau,  and  always  with  success.*  For  some  years 
various  authors  have  published  remarkable  results 
obtained  in  like  fashion.  In  any  case,  we  do  not 
want  to  infer  that  this  method  has  any  special 
originality,  but  merely  that  this  idea  of  sealing  the 
dental  splint  with  cement  seems  to  us  simple,  and 
likely  to  appeal  to  the  intelligence  of  a  large  number 
of  practitioners,  for  the  very  reason  that  this  mode 
of  retention  is  in  daily  use  for  certain  modern  dental 
appliances. 

It  has  been  suggested  to  use,  as  a  rigid  splint, 
Angle's  bands  sealed  on  to  the  neighbouring  teeth 
and  joined  by  cylindrical  screws  fixed  by  nuts.  An 
appliance  so  constructed  will  give  satisfactory  results 
in  cases  of  fracture  with  slight  displacement,  but  it 
is  found  to  be  absolutely  inferior  in  refractory  cases. 

*  Sebileau  and  Lemerle,  "  New  Appliance  for  Fracture 
of  the  Mandible  "  (Soc.  de  Chirurgie,  Mars,  1908). 

20 


3o6  INJURIES  OF  THE  FACE  AND  JAW 

This  will  be  understood  if  one  reflects  on  the  small 
number  of  its  points  of  support  and  on  the  weakness 
of  splints  built  on  these  principles.  To  get  good 
results  in  all  cases  of  fracture  in  which  a  sealed 
trough  can  be  used,  it  is  necessary  that  the  latter 
should  comprise  the  entire  dental  arch,  so  as  to  be 
able  to  take  a  sufficient  point  d'appui  and  be  em- 
bodied with  the  whole  jaw.  In  the  following  two 
conditions  the  use  of  a  sealed  trough  is  impracticable : 

1.  A  jaw  w^hich  is  edentulous,  or  equipped  with 
teeth  which  totter  in  their  sockets  and  cannot  give 
the  splint  a  solid  purchase. 

2.  A  fracture  passing  behind  the  third  molar,  or 
the  absence  of  any  tooth  on  the  posterior  fragment. 
[This  second  heading  may  be  summarized  by  the 
definition,  "  A  fracture  posterior  to  the  last  existing 
tooth."— Tr.] 

Apart  from  these  two  conditions,  the  sealed  trough 
constitutes,  in  our  view,  the  treatment  of  choice 
for  all  fractures  of  the  body  of  lower  jaw.  Its 
manufacture  is  the  simplest  thing  possible.  Formerly 
we  used  to  stamp  these  gutters  after  the  usual  manner 
of  metal-stamping — after  cutting  them  out  of  a  plate 
of  silver  or  dental  alloy.  But  now  for  several  years 
we  have  been  using  Solbrig's  plan  of  casting  in  wax, 
and  we  generally  make  the  trough  of  silver  or  pure 
aluminium.  Having  placed  the  trough  on  the 
model,  we  articulate  it  with  the  upper  jaw  in  such  a 
way  as  to  make  the  elevation  of  the  dental  articula- 
tion hardly  noticeable.  This  result  is  obtained  with 
a  file  by  reducing  all  those  points  on  the  opposing 
surfaces  of  the  gutter  which  hamper  the  articulation. 


TROUGHS  307 

Well  articulated  and  polished,  the  trough  is  now 
sealed  with  cement  after  taking  the  usual  care  in 
cleansing  and  drying  the  crowns  of  the  teeth.  For 
some  minutes,  until  the  cement  has  gripped  well, 
the  fragments  are  held  with  the  hand;  and  it  only- 
remains  to  cleanse  the  patient's  mouth  of  the  debris 
of /cement,  an  excess  of  which  was  used  in  sealing. 
As  a  fact,  it  is  generally  unnecessary,  with  sealed 
troughs,  to  apply  a  sling  or  a  bandage  to  the  patient, 
and  this,  again,  is  one  of  the  great  advantages  of 
the  method.  As  soon  as  the  trough  is  fitted,  the 
invalid  ceases  to  suffer,  and  finds  himself  astonished 
at  the  feeling  of  well-being  which  he  enjoys.  Many 
a  time  we  have  seen  patients  take  their  food  an  hour 
after  the  gutter  has  been  sealed  on,  and  masticate 
solid  food  easily. 

The  absence  of  a  chin-splint,  moreover,  constitutes 
another  advantage,  since  it  allows  a  man  the  easier 
to  resume  his  occupations.  The  consolidation  of  a 
fracture  of  the  lower  jaw  is  long;  as  we  shall  see  later, 
it  may  take  from  forty  to  sixty  days.  A  patient 
who  wears  a  sealed  trough,  which  is  invisible  and  so 
little  tiresome  that  he  forgets  its  existence,  can  take 
up  his  work  again  as  soon  as  he  has  the  appliance — 
that  is,  of  course,  if  he  has  no  other  concomitant 
lesions.  This  was  the  case  with  many  of  our  patients 
who  came  once  a  week  simply  for  us  to  verify  the 
condition  of  their  sealed  troughs.  Nevertheless,  in 
certain  less  favourable  cases,  it  is  essential  to  supple- 
ment the  sealed  trough,  at  any  rate  for  the  first  few 
days,  by  the  wearing  of  a  sling  or  elastic  bandage. 
This  will  occur  when — 


3o8  INJURIES  OF  THE  FACE  AND  JAW 

1.  A  wound  of  the  soft  parts  requires  a  dressing. 

2.  There  is  a  fracture  in  which  one  of  the  fragments 
undergoes  a  very  unusual  displacement — depression. 
This  happens  in  double  fractures,  wherein  the  middle 
piece,  especially  if  it  is  in  front,  requires,  if  it  is  to 
be  well  reduced,  the  aid  of  a  chin-splint. 

Lastly,  there  are  fractures  in  which  the  bony  dis- 
placement is  impossible,  or  at  best  difficult,  of  cor- 
rection, if  this  correction  is  to  be  maintained  by  a 
gutter.  This  eventuality  may  occur  in  two  classes 
of  case  (of  course  we  except  the  condition  in  which 
a  foreign  body,  tooth,  or  bone  splinter,  placed  in  the 
track,  prevents  coaptation)  : 

1.  The  fracture  is  recent,  and  muscular  contrac- 
tion is  such  as  to  resist  reduction. 

2.  The  fracture  is  already  one  of  long  standing, 
and  adhesions  have  had  time  to  form  and  oppose 
reduction,  [This  is  a  common  finding  after  gunshot 
injuries.  The  adhesions  may  be  divided  under  local 
anaesthesia,  and  Stent's  packed  in  to  prevent  them 
re-forming.  After  the  ansesthetic  effect  has  worn  off, 
the  Stent's  is  remarkably  well  tolerated  by  the  raw 
surface  during  healing. — Tr.]  We  shall  see,  apropos 
of  the  treatment  of  jaw  fractures  by  Martin's 
wedge  method,  how  it  is  possible  to  solve  these 
difficulties. 


FRACTURE  OF  MANDIBLE  309 

CHAPTER  IV 

TREATMENT  OF  FRACTURES  OF  THE  MANDIBLE 
BY  THE  METHOD  OF  CL.  MARTIN* 

Cl.  Martin,  noting  that  the  movement  of  opening  the 
mottth  initiated  the  natural  loweri^ig  of  the  posterior 
fragments  [the  italics  are  the  Translator's]  thought 
of  utilizing  this  peculiarity  in  treating  fractures  of 
the  mandible.  He  was  not  slow  in  noting  that  the 
chief  obstacle  to  the  reduction  of  the  fragments  was 
brought  about  by  muscular  contracture,  and  that 
mobilization  and  massage  had  a  favourable  influence 
on  the  latter.  As  the  result  of  his  observations, 
Martin  gave  up  the  double  splint  appliance  which 
we  described  above,  and  reduced  his  instrumentation 
to  three  essential  procedures:  (i)  Interdental  wedges; 
(2)  troughs;  (3)  rubber  bands  as  a  sling  beneath 
the  chin. 

The  treatment  depended  on  the  following  genera 
principles : 

1.  Reduction  of  the  fracture,  obtained  by  means 
of  interdental  wedges;  we  force  open  the  patient's 
mouth,  and  lower  the  mandible. 

2.  Massage  and  systematic  movement  of  the 
fragments  facilitate  reduction  by  reducing  muscular 
contracture. 

3.  To  keep  the  fracture  reduced,  a  buccal  splint 

*  Cl.  Martin,  "  The  Simplification  of  ^Methods  of  Treatment 
of  Fractures  of  the  Mandible,"  Lyons,  1899;  Storck,  edit. — 
Cl.  and  Fr.  Martin,  "  On  a  Simplified  Method  of  treating 
Fractures  of  the  Mandible,"  21^  Congres  fran^ais  de  chir- 
urgie,  Paris,  1908, 


3 TO  INJURIES  OF  THE  FACE  AND  JAW 

suffices.     It  consists  of  a  trough  made  to  a  mould 
of  the  dental  arch  as  it  was  before  the  accident.      • 

Having  laid  down  these  principles  Martin  applied 
his  method  as  follows : 

I.  Reduction  of  the  Fracture. — "The  reduction  of 
the  fracture  is  achieved,"  says  CI.  Martin,  "  by 
making  the  patient  take  up  the  position  of  '  mouth 
open,'  by  mobilizing  the  fragments,  and  by  massaging 
the  region  of  fracture.  When  we  make  a  man, 
whose  lower  jaw  is  broken,  open  his  mouth,  the 
fragments  tend  to  be  spontaneously  reduced.  This 
fact  had  already  been  noted  by  Malgaigne,  Laborde, 
and  Cluseaux,  who,  however,  had  never  drawn  the 
practical  inference.  It  is,  indeed,  this  physiological 
fact  of  which  we  avail  ourselves  to  obtain  reduction 
of  the  fracture.  [It  would  seem  better  to  refer  to 
any  phenomenon  in  connection  with  a  broken  jaw 
as  pathological,  rather  than  physiological. — Tr.] 
To  maintain  this  reduction,  it  suffices  to  make  per- 
manent the  position  of  '  mouth  open,'  by  means  of 
wooden  or  cork  wedges  placed  between  the  two  jaws. 

"  In  the  normal  state,  when  the  mouth  is  opened, 
the  depressor  muscles  involve  the  whole  mandible 
in  the  movement.  But  when  there  is  a  solution  of 
continuity  of  the  bone,  the  muscular  equilibrium  is 
upset,  and  antagonistic  muscles  can  act  in  opposite 
directions.  Picture,  in  fact,  a  single  fracture  tracking 
between  the  right  bicuspids  and  canine.  The  left, 
longer  fragment  tends  to  fall  by  its  own  weight,  and 
is  pulled  downwards  and  backwards  by  the  depressor 
muscles,  which  in  virtue  of  the  solution  of  bony 
continuity  have  become  retractors. 


REDUCTION  OF  FRACTURE  .^iii 

"  If,  then,  we  make  the  subject  open  his  mouth, 
the  right  lower  fragment  is  drawn  downwards  by 
the  depressor  muscles;  and  if  we  interpose  between 
it  and  the  maxilla  an  obstacle,  such  as  a  wedge,,  to 
resist  its  reascent,  we  shall  see  that  the  act  of  opening 
the  mouth  has  brought  the  posterior  fragment  level 
with  the  anterior.  It  is  only  in  a  fracture  between 
the  central  incisors  that  the  displacement  can  be  nil ; 
for  the  bilateral  muscles,  acting  on  equal  arms  of  a 
lever,  are  balanced.  Even  in  this  case,  however,  one 
may  observe,  produced  directly  by  the  trauma  or 
due  to  the  obliquity  of  the  fracture,  a  displacement; 
this  is  as  a  rule  easily  reducible. 

"  Now  imagine  a  double  fracture,  passing  on  each 
side  between  premolars  and  molars.  Here  we  have 
two  posterior  and  one  median  fragment.  The  latter, 
under  the  action  of  the  depressor  muscles  (which 
behave  like  retractors,  as  above  explained),  is  drawn 
downwards  and  backwards,  and  simultaneously 
rotates  round  a  coronal  axis,  so  that  its  alveolar 
margin  swings  forwards.  The  posterior  fragments 
remaining  in  contact  with  the  maxillae,  we  get  a 
characteristic  yawning  gap  between  the  incisors  of 
the  two  jaws.  If  now  we  make  the  wounded  man 
open  his  mouth,  and  we  place  a  wedge  between  the 
maxilla  and  the  posterior  fragments,  we  shall  see  the 
latter  carried  to  meet  the  anterior  fragment  and 
take  up  its  position  level  with  the  latter.  To  com- 
plete the  reduction,  we  have  only  to  correct  the 
rotary  swinging  movement  of  the  anterior  fragment. 
"  Opening  the  mouth  and  wearing  wedges  does  not 
invariably  suffice  to   bring  the   fragments   back  to 


312  INJURIES  OF  THE  FACE  AND  JAW 

their  normal  position.  But,  to  complete  the  reduc- 
tion, we  shall  find  a  valuable  ally  in  movement 
combined  with  massage.  In  fact,  what  tends  to 
immobilize  the  fragments  in  a  vicious  position  is  not 
merely  the  obliquity  of  the  fracture  tracks,  but  also, 
and  above  all,  muscular  contracture.  The  pain  of  the 
wound  provokes  a  permanent  reflex  stimulus  of  the 
muscles,  and  one  revolves,  as  it  were,  in  a  vicious 
circle;  the  displacement  of  the  fragments  aggravates 
the  contracture,  which  again  keeps  up  the  pain  and 
resists  reduction.  It  is,  then,  against  contracture 
that  we  should  fight.  And  the  best  weapons  to  over- 
come this  are,  beyond  all  dispute,  movement  and 
massage. 

"  To  carry  out  movements,  we  seize  each  fragment 
with  the  fingers.  The  thumb  placed  beneath  the 
chin,  the  index  and  middle  fingers  on  the  dental 
arches,  we  thus  work  these  fragments  in  and  out, 
up  and  down,  to  right  and  left — in  a  word,  in  all 
directions.  If  the  skin  of  the  chin  has  been  much 
involved  in  the  lesion,  and  a  wound  exists  here,  we 
can  take  hold  of  the  fragments  by  the  dental  arches. 

"  The  first  seances  of  movement  must  be  carried 
out  with  the  greatest  moderation;  it  is  better,  in  the 
early  days,  to  make  them  brief  but  fairly  frequent. 
At  first  they  will  cause  pain,  more  or  less  sharp; 
but  it  is  not  uncommon  to  find  this  disappear  after 
the  first  few  sittings.  Further,  these  manoeuvres 
very  rapidly  become  tolerable,  and  at  the  end  of 
some  days  are  hardly  at  all  painful.  To  this  passive 
movement  one  can  add  active  (performed  by  the 
patient  himself),  by  a  series  of  alternate  efforts  at 


RETENTION  AFTER  REDUCTION  313 

opening  and  closing  the  mouth,  the  wedges  staying 
in  place.  Such  movements  have  the  happiest 
results.  It  must  be  understood  that  they  cannot 
be  practised  until  painful  phenomena  are  much 
ameliorated. 

"  Movements  act  effectively  against  the  muscular 
contracture,  which  they  quickly  dispel.  It  has 
besides  an  important  mechanical  role,  for  it  undoes 
faulty  impactions,  makes  the  fracture  track  more 
regular,  eliminates  loose  splinters,  and  rounds  off 
projecting  points  which  oppose  the  approximation 
of  the  fragments.  In  a  word,  it  facilitates  good 
coaptation. 

"  Mobilization  should  be  supplemented  by  massage 
of  the  region  of  the  fracture  and  its  neighbouring 
parts.  This  massage,  exclusively  external,  is  carried 
out  on  the  whole  chin  region.  It  is  wise  to  renew  it 
as  often  as  possible,  and  to  give  it  such  a  direction 
that  it  always  tends  to  bring  the  fragments  to  their 
normal  position.  The  existence  of  extensive  wounds 
about  the  chin  is  the  only  contra-indication." 

We  have  deliberately  reproduced  verbatim  this 
passage  from  Martin's  memoir,  because  it  is  an 
exposition  of  the  most  original  principles  of  the  new 
method. 

2.  Retention  of  the  Fracture. — Having  obtained 
reduction,  Martin  maintains  it  by  a  dental  trough 
and  a  rubber  sling.  Made  according  to  a  corrected 
mould,  this  trough  is  constructed  in  vulcanized 
rubber.  Martin  gives  preference  to  this  substance 
as  being  easier  to  work  on.  He  limits  its  thickness 
to  about  1-5  mm.,  and  gets  an  accurate  coaptation 


314  INJURIES  OF  THE  FACE  AND  JAW 

by  scratching  on  the  model  the  necks  of  the  teeth 
and  the  spaces  between  them.  The  piece  is  to  be 
vulcanized  on  the  model.  The  finished  trough  is  as 
a  rule  easy  to  put  in  place.  If  one  finds  it  resistant, 
it  suffices  to  soften  the  rubber  by  steeping  it  in  warm 
water,  according  to  Martin's  plan.* 

When  movement  and  massage  have  sufficiently 
reduced  the  muscular  contracture  to  render  easy 
the  reduction  of  the  fragments,  we  should  arrange 
the  gutter  in  place.  Martin  only  applies  his  gutter 
when  he  is  confronted  by  very  mobile  fragments. 
In  this  case  he  uses  plated  steel  screws,  inserted  at 
the  levels  of  the  interdental  spaces.  A  rubber 
bandage  forming  a  submental  sling  always  follows 
the  adaptation  of  the  trough.  This  bandage,  not 
more  than  5  or  6  cm.  in  width,  pulls  the  chin  back- 
wards and  upwards,  and  insures  the  elevation  of 
the  depressed  anterior  fragment.  When  in  use  the 
bandage  requires  to  be  watched,  especially  when  there 
are  several  movable  fragments ;  for  any  lateral  pres- 
sure would  cause  an  inward  deviation.  To  avoid 
any  such  effect  of  lateral  pressure,  Martin  advises 
that  a  small  plate,  whose  margins  separate  the  band 
from  the  side  of  the  jaw,  be  placed  beneath  the  chin. 
Finally,  the  elastic  band  should  not  even  provoke 
pain;  so  it  should  be  only  moderately  tightened. 

Such  is  the  scheme  of  simplified  treatment  advo- 
cated by  Martin  of  late  years.  "  We  should  add," 
he  writes,  "  that  wedges,  trough,  and  rubber  band, 
are  to  be  worn  constantly,  day  and  night.     At  the 

*  Despite  his  great  experience,  we  mention  this  process 
of  CI.  Martin  with  all  reserve. 


TYPES  OF  FRACTURE  315 

beginning,  to  wear  the  wedges  is  quite  unpleasant; 
so  one  may  give  during  the  day  a  httle  rest  to  the 
patient,  by  removing  them  now  and  then  in  the 
course  of  the  day.  But  in  general,  after  the  second 
or  third  day,  they  are  well  enough  borne." 


CHAPTER  V 

MARTIN'S  MODES   OF  TREATMENT  ACCORDING 
TO    DIFFERENT    TYPES    OF    FRACTURE 

The  application  of  interdental  wedges  varies  with  the 
type  of  the  fracture  we  are  concerned  in  treating. 
So  it  behoves  us  to  investigate  their  use  in  each  sort 
of  case  which  can  occur: 

1.  Single  Median  Fracture. — The  fracture  tracks 
through,  or  in  the  immediate  neighbourhood  of,  the 
middle  line.  The  muscles  of  the  two  sides  are 
balanced;  there  is  little  or  no  displacement.  The 
employment  of  interdental  wedges  is  useless. 

2.  Single  Fracture  behind  the  Canine. — The  pos- 
terior fragment  i?  displaced  upwards.  To  lower  it 
one  must  open  the  mouth,  and  place  a  wedge  be- 
tween the  posterior  fragment  and  the  upper  arch 
(Fig.  149). 

3.  Bilateral  Symmetrical  Fracture,  the  Two  Tracks 
passing  between  the  Molars  of  Each  Side. — The  two 
posterior  fragments  are  elevated;  the  anterior  is 
depressed,  and  rotated  from  behind  forwards.  We 
must  place  an  interdental  wedge  over  each  posterior 
fragment  (Fig.  150). 


3i6  INJURIES  OF  THE  FACE  AND  JAW 

4.  Double  Unilateral  Fracture;  Both  Tracks  on 
the  Same  Side. — The  posterior  fragment  is  elevated; 
the  middle  fragment,  following  the  direction  of  the 
fracture,  travels  up  with  the  posterior  or  down  with 


Fig.  149. 


Fig.   150. 


Fig.  151. 


the  anterior  fragment.  An  interdental  wedge  is 
placed  over  the  posterior  fragment,  and  a  second,  if 
necessary,  over  the  middle  fragment  (Fig.  151). 
[This  figure  shows  neither  the  anterior  fracture  track 
nor  the'anterior  wedge. — ^Tr.] 


Fig.   152. 


Fig.   153. 


Fig.   154. 


5.  Double  Fracture,  Unilateral  or  Bilateral,  the 
Most  Posterior  Fracture  passing  behind  the  Wisdom 
Tooth. — If  the  two  fractures  lie  on  the  same  side, 
the  middle  fragment  is  pulled  up  by  the  masseter; 
and  reduction  is  difficult,  since  the  ascending  ramus 
of  the  maxilla   affords   no   purchase.     We   place   a 


TYPES  OF  FRACTURE  317 

wedge  over  the  middle  fragment  (Fig.  152).  If  the 
second  fracture  hes  on  the  opposite  side,  we  place 
another  wedge  in  front  of  this  fracture  (Fig.  153). 

6.  Unilateral  Double  Fracture,  One  Track  passing 
behind  the  Canine,  the  Other  near  the  Condyle. — 


Fig.  155. 


Fig.   156. 


Fig.   157. 


Lower  the  fragment  as  a  whole  by  placing  a  wedge 
opposite  the  wisdom  tooth  (Fig.  153).  [Wedge  not 
shown  in  figure. — Tr.] 

7.  Fracture   of   One   Condyle. — If  the   interdental 
articulation   is   intact   on   the   side   of  the   fracture, 


Fig.  158. 


Fig.   159. 


there  will  not  be  any  displacement.  If  one  of  the 
jaws  is  edentulous,  on  the  contrary,  there  will  be  a 
backward  retraction  of  the  jaw  on  the  fractured  side. 
To  deal  with  this  retraction,  one  may  employ  the 
appliances  used  for  the  correction  of  vicious  scars 
after    the   resection   of   a    part   of   the   lower   jaw. 


3i8  INJURIES  OF  THE  FACE  AND  JAW 

CI.  Martin  has  made  use  of  an  apparatus  made  up 
as  follows: 

{a)  A  metal  trough  covering  the  lower  dental  arch 
on  the  side  of  the  fracture.  At  the  front  of  this 
gutter  is  soldered  a  rod,  ending  in  a  ring  and  pro- 
jecting out  of  the  mouth  about  3  cm. 


Fig.   160. 

{b)  A  head-band  encircling  the  head  at  the  level' 
of  the  temples;  it  carries  on  the  side  of  the  fracture 
a  vertical  metal  rod  coming  down  to  the  mouth. 
A  rubber  thread  stretched  between  the  end  of  this  rod 
and  the  buccal  trough  enables  us  to  apply  acontinuous . 
outward  traction  on  the  deviated  jaw  (Fig.  .160). 


TYPES  OF  FRACTURE  319 

One  of  us  has  obtained  good  results  with  the 
following  arrangement:* 

(a)  A  metal  trough  sealed  on  to  the  dental  arch  on 
the  fractured  side. 

(b)  A  metal  trough  sealed  on  to  the  upper  dental 
arch  on  the  opposite  side. 

Two  small  hooks  soldered  on  to  the  outer  surfaces 
of  the  troughs  enable  one  to  stretch  an  elastic  band 
between  them;  its  traction  carries  the  deviated  man- 
dible outwards. 

8.  Fracture  of  Both  Condyles  (Fig.  156). — Often 
such  fractures  do  not  unite,  and  end  in  the  formation 
of  pseudarthroses.  This  does  not  constitute  a  serious 
disability  if  the  interdental  articulation  is  good  and 
resists  backward  displacement  of  the  mandible. 
Conversely,  if  the  jaws  lack  some  of  their  teeth,  this 
accident  may  occur.  In  such  a  case  the  indication 
is  to  remedy  it  by  re-establishing  the  height  of  the 
arches  by  dental  prosthetic  fittings  suitably  articu- 
lated. 

9.  Unilateral  Fracture  in  the  Middle  of  a  Region 
destitute  of  Teeth. — We  should  fill  up  the  gap  of  the 
dental  arch  by  a  piece  of  vulcanized  rubber,  placed 
in  the  trough  and  opposing  the  displacement  of  the 
fragments.  A  wedge  is  placed  on  top  of  the  gutter 
over  the  posterior  fragment  (Fig.  157). 

10.  Unilateral  or  Bilateral  Fracture  of  a  Mandible 
lacking  all  its  Molars,  the  Track  passing  through  the 
Region  formerly  occupied  by  these  Teeth  (Fig.  158). — 

*  G.  Lemerle,  "  Appliance  to  reduce  Cicatricial  Retrac- 
tion after  Partial  Resection  of  the  Lower  Jaw  "  [Labora- 
toire,  Dec,  1907). 


320  INJURIES  OF  THE  FACE  AND  JAW 

We  should  apply  a  trough,  of  which  the  posterior 
ends  are  thick  enough  to  fill  the  chasm  left  by  the 
missing  teeth,  and  to  re-establish  the  continuity  of 
the  articulation.  We  then  place  wedges  between 
the  jaws  on  top  of  the  troughs,  over  the  posterior 
fragment.  In  the  presence  of  a  unilateral  fracture 
of  a  mandible  devoid  of  all  teeth,  except  the  four 
incisors,  one  of  us  has  employed  the  following  method. 
The  case  in  question  was  a  patient  of  M.  Sebileau. 
The  fracture  lay  in  front  of  the  region  occupied  for- 
merly by  the  wisdom  tooth;  the  displacement  of  the 
posterior  fragment  was  considerable.  To  obtain  and 
retain  its  depression,  we  simply  fitted  a  rubber 
appliance  to  the  patient.  It  resembled  a  denture; 
but  its  posterior,  very  thick  part  overlay  the  articula- 
tion in  such  a  way  that  the  patient  was  compelled 
to  keep  the  mouth  open.  Thus  the  posterior  frag- 
ment became  reduced  with  ease,  and  the  patient 
made  an  uneventful  recovery.  In  fact,  it  seems  to 
us  that  in  such  a  case  it  is  advantageous  to  avoid 
the  use  of  an  interdental  splint,  by  merely  thickening 
the  back  part  of  the  trough  on  the  mandible. 

II.  Bilateral  Fracture  of  the  Molar  Region  of  an 
Edentulous  Jaw,  with  Fracture  Tracks  which  pass 
far  back  to  the  Junction  of  the  Ascending  Ramus  and 
Body  of  the  Mandible  (Fig.  159). — This  type  of  frac- 
ture, of  which  the  pathology  has  been  brought  to 
light  by  CI.  Martin,  deserves  to  attract  special  atten- 
tion. For  such  a  fracture  one  should  apply  to  the 
patient  a  rubber  trough  articulating  to  a  nicety 
with  the  upper  jaw,  and  the  raising  of  the  articu- 
lating surface  of  the  teeth  must  be  carefully  avoided. 


FRACTURES  OF  MANDIBLE  321 

It  is  absolutely  contra-indicated  to  use  wedges  between 
the  jaws;  for  the  position  "mouth  shut"  must  be 
substituted  for  the  position  "  mouth  open."  And  this 
is  the  reason:  The  posterior  fragments — on  which, 
moreover,  we  cannot  get  any  purchase — are  kept  in 
a  normal  position  when  the  mouth  is  closed.  This 
does  not  apply  to  the  anterior  fragment,  which 
consists  of  the  body  of  the  lower  jaw,  of  which  only 
the  anterior  part  carries  teeth.  The  anterior  fibres 
of  the  masseter  are  inserted  into  the  posterior  part 
of  the  anterior  fragment.  These  fibres  pull  up  this 
posterior  part  of  this  fragment;  the  anterior  part 
swings  down,  thus  producing  the  gaping  mouth. 
The  displacement  is  such  that  the  anterior  fragment 
is  raised,  in  relation  to  the  mandibular  angle  (posterior 
fragment),  because  the  former  carries  no  molar  teeth 
which,  by  their  articulation  with  their  antagonists 
above,  could  resist  this  ascending  and  rotary  move- 
ment. The  pathological  data  lead  us  to  the  following 
conclusions :  In  certain  ver}"  special  cases  of  fractured 
mandible,  to  open  the  mouth  is  wwfavourable  to 
reduction.  In  these  cases  the  mouth  should,  there- 
fore, be  kept  closed,  and  the  dental  arches  in  exact 
occlusion.  We  shall  get  this  result  with  the  help  of 
a  trough  which  restores  the  edentulous  mandible  to 
its  normal  height,  and  the  addition  of  an  elastic 
sling  to  hold  the  upper  and  lower  jaws  in  apposition. 
The  use  of  wedges  should  therefore  be  entirely 
suppressed. 


21 


322  INJURIES  OF  THE  FACE  AND  JAW 

CHAPTER  VI 

GENERAL   CONCLUSIONS   ON   THE   TREATMENT 
OF   FRACTURES   OF   THE   LOWER   JAW 

After  this  lengthy  review  of  the  numerous  methods 
recommended  for  the  treatment  of  fractured  man- 
dibles, it  is  convenient  to  put  ourselves  the  following 
question :  Confronted  by  a  case  of  fractured  mandible, 
what  is  to-day  the  course  to  pursue  ?  The  answer 
to  this  question  will  form  the  conclusion  of  our 
study.  At  the  risk  of  repetition,  let  us,  then,  rapidly 
review  the  treatments  at  our  disposal: 

1.  Bandages  and  slings,  employed  alone,  are  in- 
sufficient to  maintain  reduction,  and  can  only  be 
temporary  means  of  immobilization.  In  conjunction 
with  the  wearing  of  a  dental  splint,  they  constitute 
a  help  which  is  useful,  but  not  always  indispensable. 

2.  Bone  suture  and  ligature  of  fragments  are 
septic  operations  which  place  foreign  bodies  in  the 
neighbourhood  of  an  open  fracture.  They  can 
achieve  the  continuity  of  the  bone,  but  cannot  assure 
the  preservation  of  the  interdental  articulation. 
Indeed,  they  take  no  count  of  this,  and  so  do  not 
produce  a  good  functional  cure. 

3.  Double  splint  appliances  not  made  to  a  mould 
of  the  reconstituted  dental  arch  are  equally  incapable 
of  assuring  a  functional  cure. 

4.  Double  splint  appliances  made  to  a  corrected 
mould  can  assure  this  cure;  and  until  late  years  they 
constituted  the  treatment  of  choice  for  fractures  of 
the  mandible. 


CONCLUSIONS  323 

5.  Single  splint  appliances  made  to  a  mould  are 

less  irksome  to  patients  than  those  with  a  double 
splint.  Their  value  is  only  as  great  if  they  are  very 
firmly  fixed  on  to  the  dental  arch.  The  best  of  these 
processes  is  to  seal  metal  troughs  on  to  the  teeth 
with  cement. 

6.  Martin's  wedge  method  is  an  immense  step  in 
the  treatment  of  fractured  mandibles.  He  has  shown 
the  advantages  of  massage  and  movement  to  check 
muscular  contracture,  the  principal  obstacle  to 
reduction. 

Studying  the  pathology  of  the  most  diverse  cases 
of  fracture,  he  has  shown  w^hat  marvellous  use 
could  be  made  of  intermaxillary  wedges  to  depress 
certain  fragments,  using  at  the  same  time  a  dental 
splint. 

We  consider  that  to-day  the  best  treatment  is  that 
which  associates  CI.  Martin's  methods  of  reduction 
with  sealed  troughs  to  immobilize  when  reduction  has 
been  completed. 

Given  a  case  of  fracture  of  the  mandible  (for 
example,  a  single  track  passing  between  the  second 
and  third  molars),  we  should  proceed  as  follows: 

I.  We  must  assure  antisepsis  of  the  buccal  region, 
which  communicates  wdth  the  focus  of  a  compound 
fracture.  To  this  end  we  have  copious  and  frequent 
irrigations  of  the  mouth  carried  out,  with  an  irrigator 
and  a  glass  cannula.  "  For  this  either  boiled  water, 
or,  better,  a  solution  of  chloral  i  in  200,  P  naphthol 
4  per  cent.,  or  iodine,  may  be  used.  Ombredanne 
says  that  excellent  results  are  daily  being  obtained 
with  a  solution  of  tinct.  iodi,  150  or  200  drops  to 


324  INJURIES  OF  THE  FACE  AND  JAW 

the    litre    of     cold    (preferably    filtered    or    boiled) 
water."* 

Often  the  partial  occlusion  of  the  jaws  which 
follows  a  fracture  will  make  it  difficult  to  carry  out 
irrigations.  In  this  case  (if  there  is  no  space  in  the 
front  or  at  the  sides,  produced  by  the  absence  of  one 
or  more  teeth),  we  should  avail  ourselves  of  the  buccal 
vestible,  and  of  the  cavity  existing  between  the  last 
molar  and  the  ascending  ramus  of  the  mandible,  to 
introduce  the  cannula. 

2.  We  must  reduce  the  fracture,  not  always  an 
easy  matter  when  there  are  great  displacements. 
In  this  case  we  shall  use  CI.  Martin's  method.  By 
massage  and  movement  we  make  the  muscular  con- 
tracture give  way,  and  intermaxillary  wedges  judici- 
ourly  placed  will  assist  in  the  reduction.  These 
wedges  can  be  made  very  easily  and  practically  with 
corks  of  a  convenient  size,  and  preferably  bevelled 
at  one  end.  It  is  a  wise  precaution  to  attach  a  thread 
which,  passing  out  of  the  mouth,  not  only  makes 
them  easy  to  withdraw,  but  prevents  an  accidental 
slip  into  the  pharynx.  Wedges  may  equally  well  be 
made  of  soft  rubber.  In  any  case  they  should  never 
be  of  vulcanite,  nor,  in  general  terms,  of  any  incom- 
pressible material.  Intermaxillary  wedges  are  forced 
between  the  arches  at  that  point  necessitated  by  the 
displacement  of  fragments;  and  their  sole  means  of 
retention  lies  in  the  contracture  which  it  is  their  task 
to  overcome. 

*  Ombredanne,  "  New  Treatise  on  Surgery,"  by  Le 
Dentu  and  Delbet;  section  xvi.,  "Diseases  of  the  Jaws," 
p.  i6. 


CONCLUSIONS  325 

3.  When  the  muscular  contracture,  the  chief 
factor  in  the  displacement  of  the  fragments,  is 
weakened,  we  take  a  mould  of  the  arches.  That  of 
the  lower  arch  is  to  be  brought  to  a  normal  occlusion, 
and  on  it  we  then  construct  a  trough,  preferably  of 
metal  cast  in  wax. 

4.  When  the  fragments  have  become  easily  re- 
ducible, the  dental  trough  is  to  be  sealed  firmly 
with  cement;  and,  thanks  to  its  absolute  fixation, 
the  reduction  of  the  fracture  is  thus  maintained, 
without  as  a  rule  any  necessity  of  resorting  to  the 
help  of  a  rubber  sling.  We  shall  thus  have  applied 
a  treatment  which  is  very  simple,  reducing  to  a 
minimum  the  distress  imposed  on  the  patient,  and 
insuring  perfect  results.  We  think  that  this  is  the 
best  mode  of  treatment  in  all  cases  of  fractured 
mandible  to  which  it  is  applicable,  as  it  is  to  the 
majority.  We  have  above  pointed  out  the  modifica- 
tions which  must  be  made  in  the  trough  for  fractures 
of  partly  or  completely  edentulous  mandibles;  in 
such  cases  the  trough  should  be  in  vulcanized  rubber, 
and  of  course  not  sealed. 

In  the  unique  class  of  case  (No.  11  of  CI.  Martin, 
above)  where  we  have  to  inflict  "  mouth-shut  " 
position  on  the  patient,  he  should  wear  a  rubber 
sling.  Finally  let  us  refer  to  the  cases  of  deviation 
of  fragments  which  necessitate  the  wearing  of  an 
elastic  traction  appliance.  We  have  described  these 
appliances;  it  should  be  added  that  they  can  render 
the  greatest  services  in  certain  fractures  treated  after 
some  delay,  also  where  the  displacement  of  the 
fragments  is  kept  up  by  fibrous  adhesions.     Elastic 


326  INJURIES  OF  THE  FACE  AND  JAW 

traction  makes  them  yield  rapidly,   and  allows  us 
to  obtain  a  good  reduction. 

I.  Duration  of  Treatment. — It  is  wise  to  leave  the 
trough  in  place  long  enough,  about  a  fortnight  after 
the  consolidation  seems  to  be  certain.  The  time 
demanded  for  consolidation  is  quite  variable.  CI. 
Martin  gives  the  following  figures : 

From  20  to  30  days       . .  . .     8  cases. 

,,      30  „  40     „  ..  ..6     „ 

,,     40  »  50     >»         ••  ••     5     » 

„      50  „  60     „         ..  ..4     ,, 

Our  personal  experience  has  taught  us  that  the 
average  duration  is  from  thirty  to  fort}^  days.  Some- 
times consolidation  hangs  fire  on  account  of  the  onset 
of  osteitis  near  the  focus  of  an  infected  fracture. 
Then  we  get  one  or  more  abscesses,  which  apparently 
always  point  on  the  vestibular  surface  of  the  jaw; 
we  have  never  seen  them  come  to  the  surface  on  its 
buccal  aspect.  [In  gunshot  injuries,  with  massive 
damage  to  the  soft  parts  followed  by  their  extensive 
cicatricial  adhesion  to  the  fractured  bone,  the  abscess 
usually  passes  right  across  the  vestibule,  which  is 
often  practically  obliterated  by  scar  tissue,  and 
points  outside  on  the  face  or  neck.  The  result  is 
sinus  formation,  which,  if  it  communicates  also  with 
the  mouth,  constitutes  a  salivary  fistula. — Tr.] 
One  or  more  sequestra  are  cast  oft';  when  a  probe 
reveals  the  presence  and  mobility  of  these  beneath 
the  mucosa,  we  ought  to  remove  them.  The  incision 
of  abscesses,  the  removal  of  sequestra,  and  the 
lavage  of  the  focus,  should  be  carried  out,  of  course, 
without   interfering   with  the   sealed   gutter,   which 


COMPLICATIONS  327 

should  only  be  removed  after  consolidation.  In 
sixteen  cases  of  fracture  we  have  seen  abscess  forma- 
tion and  sequestration  only  three  times.  Such 
sequelae  usually  happen  about  three  weeks  after  the 
trough  has  been  sealed  on. 

2.  Considerations  on  Certain  Secondary  Complica- 
tions of  Fractures  of  the  Mandible. — Gunshot  injuries 
may  end  in  extensive  loss  of  substance  of  the  jaw. 
In  other,  exceptional  cases,  the  infection  of  the  site 
of  fracture  may  involve  a  massive  necrosis  of  the 
ends  of  the  fragments,  and  result  in  the  formation 
of  large  sequestra  involving  both  bony  tables  for 
their  whole  length  and  height.  Such  sequestra  may 
be  several  centimetres  long.  [This  must  indeed  be 
exceptional.  Amidst  the  large  number  of  massive 
gunshot  wounds  of  the  jaw  which  I  have  dealt  with 
since  June,  1916,  I  have  never  seen  such  a  con- 
dition. Moreover,  if  both  tables  are  thus  involved 
the  diploe  could  hardly  escape;  and  osteomyelitis 
would  rob  the  patient  of  his  whole  jaw,  and  probably 
of  his  life. — Tr.]  The  natural  outcome  is  a  true 
shortening  of  the  mandibular  arc.  In  such  a  case 
we  find  ourselves  in  the  following  dilemma:  Shall 
we  aim  at  bony  consolidation  by  insuring  coaptation 
of  the  fragments  after  eliminating  sequestra — that 
is,  make  sure  of  the  continuity  of  the  jaw  by  sacri- 
ficing the  interdental  articulation  ?  Or,  rather, 
preserve  the  articulation  by  renouncing  attempts 
to  consolidate  the  fracture  ?  We  range  ourselves 
with  the  votaries  of  the  latter  plan,  and  frankly 
share,  on  this  point,  the  views  of  Mahe.  In  fact, 
we  cannot  claim  as  a  cure  the  consolidation  achieved 


328  INJURIES  OF  THE  FACE  AND  JAW 

with  such  a  degree  of  shortening  that  the  interdental 
bite  is  destroyed.  The  continuity  of  the  jav/  is 
re-estabhshed,  but  the  patient  cannot  chew.  To 
this  a  pseudarthrosis  would  be  vastly  preferable. 
Immediate  prosthesis  can  be  of  the  greatest  use  in 
such  cases.  After  a  loss  of  tissue  involving  a  shorten- 
ing of  the  mandibular  arch,  the  fragments  can  be 
straightened,  and  the  invalid  treated  as  if  he  had 
undergone  a  partial  resection  of  the  lower  jaw. 

A  block  of  vulcanized  rubber  fixed  in  the  wound 
prevents  cicatricial  retraction  (immediate  prosthesis). 
When  the  wound  is  completely  epithelialized,  this 
rubber  block  is  lifted  out,  and  yields  its  place  to  an 
ordinary  removable  dental  appliance  (late  pros- 
thesis). The  base  of  this  restores  the  continuity  of 
the  jaw,  and  fills  the  cavity  left  by  the  lost  piece  of 
bone.  From  this  time  onwards,  the  patient  possesses 
an  intact  interdental  articulation.  Surely  such  a 
functional  cure  is  preferable  to  an  anatomical  cure; 
for,  in  the  latter  case,  to  consolidate  is  to  make 
certain  of  losing  all  function.  Unfortunately,  the 
resources  of  prosthesis  are  still  unknown  to  most 
surgeons.  In  our  day  immediate  prosthesis  is  not 
regarded  by  everyone  as  the  indispensable  comple- 
ment of  any  jaw  resection.  In  the  case  of  the  loss 
of  substance  by  fracture,  it  has,  at  any  rate  as  far 
as  we  know,  never  been  used.  In  fact,  confusion 
reigns  between  immediate  and  internal  prosthesis, 
and  certain  surgeons  who  recommend  suture  speak 
of  the  inevitable  (soon  or  late)  elimination  of  appli- 
ances of  immediate  prosthesis,  and  of  their  failure. 
They  do  nQt  know  that  an  immediate  prosthesis  i§ 


CONCLUSIONS  329 

an  external  one,  essentially  provisional,  which  makes  ** 
no  allowance  for  the  tolerance  of  the  tissues,  and 
that  its  precise  destiny  is  to  be  removed  at  the  end 
of  several  weeks.  Then  the  late  prosthesis  is  placed, 
and  its  role  is  limited  to  preventing  cicatricial  re- 
traction. 


SECTION    II 

TREATMENT  OF  FRACTURES  OF 
THE  UPPER  JAW 


CHAPTER  I 

GENERALITIES 

Fractures  of  the  maxilla  fall  into  two  groups: 
partial  and  extensive.  Partial  fractures  comprise 
those  of  the  alveolar  margin,  body,  and  maxillary 
sinus.  Among  these,  fractures  of  the  alveolar 
margin  are  the  only  ones  which  interest  us  because 
their  treatment  claims  the  ministrations  of  the 
dentist.  Extensive  fractures  are  produced  (as  at 
the  base  of  the  skull)  along  lines  of  diminished 
resistance,  and  are  determined  by  the  beams  and 
struts  which  take  strains  (to  borrow  the  terminology 
of  engineering),  which,  again,  depend  upon  the 
architecture  of  the  maxillae  and  of  the  facial  scaffold- 
ing. Extensive  fractures  comprise  intermaxillary 
disruption,  horizontal  fractures,  and  cranio-facial 
severance,  all  of  which  interest  us,  since  to  deal  with 
them  we  must  draw  on  the  resources  of  the  pros- 
thesist. 

330 


FRACTURES  OF  MAXILLA  331 

Intermaxillary  disruption  is  as  a  rule  produced  by 
a  concussion  on  the  chin  from  below  upwards.  It 
is  more  than  likely  that  the  lower  dental  arch,  being 
contained  by  the  upper,  by  its  impact  on  the  latter 
causes  disruption;  this  would  be  facilitated  by  any 
defects  of  articulation  which  allow  the  lower  teeth 
to  slide  towards  the  buccal  aspect  of  the  upper.  In 
such  fractures  one  can  demonstrate  an  outward 
displacement  of  the  two  upper  jaws,  and  the  dis- 
appearance of  the  interdental  bite.  The  separation 
of  the  jaws  may  amount  to  i  cm. 

Horizontal  fractures  may  occur  in  two  different 
types: 

1.  TTie  track  detaches  the  whole  alveolar  margin  en 
masse,  so  that  it  is  no  longer  held  up  except  by 
the  gums.  The  upper  arch  lies  on  the  lower  like  a 
denture.     This  is  a  very  rare  fracture. 

2.  The  horizontal  fracture  of  Guerin,  much  more 
common,  detaches  en  masse  the  lower  part  of  the 
maxillae,  above  the  palatine  vault.  These  fractures 
are  as  a  rule  the  result  of  a  violent  horizontal  blow 
below  the  nose. 

Cranio-facial  severance  occurs  when  a  double 
trauma,  exercised  in  opposite  directions  on  the  chin 
and  the  cranial  •  vault,  causes  an  actual  propulsion 
upwards  and  forwards.  The  same  severance,  but 
with  a  propulsion  of  the  maxillae  in  the  opposite 
direction,  can  result  from  a  violent  blow  on  the  root 
of  the  nose.  Lastly,  Walter  has  described  an  enor- 
mous fracture  in  four  fragments,  which  is  seen  when 
with  a  cranio-facial  severance  there  coexists  an 
intermaxillary  disruption  and  a  fracture  of  Guerin. 


332  INJURIES  OF  THE  FACE  AND  JAW 

CHAPTER  II 

TREATMENT    OF    PARTIAL    ALVEOLAR 
FRACTURES 

These  involve  especially  the  external  table,  and 
generally  in  the  incisor  region.  As  a  rule  they 
accompany  a  fracture  of  the  mandible,  especially 
when  this  latter  only  carries  teeth  in  its  anterior 
part.  In  fact,  in  this  case,  the  shock  which  is  borne 
by  the  mandible,  and  which  causes  the  break,  deter- 
mines at  the  same  time  an  alveolar  fracture  in  the 
upper  incisor  region,  being  transmitted  to  this  latter 
by  the  intermediary  of  the  lower  incisor  mass.  The 
front  of  the  external  table  of  the  maxilla  is  crushed, 
and  yields  to  the  shock  of  the  lower  teeth,  which 
form  a  wedge  in  that  region.  We  have  noticed  that 
when  the  jaws  carry  all  their  teeth  this  partial 
fracture  does  not  occur;  in  fact,  in  such  a  case  the 
only  fracture  which  is  likely  to  result  is  an  inter- 
maxillary disruption,  which  has  a  similar  mechanical 
causation  to  the  former.  But  the  latter  fracture  is 
vastly  more  rare,  because  the  violence  of  the  trauma 
transmitted  to  the  upper  jaw  is  much  diluted  by  its 
being  spread  over  all  the  points  of  the  two  intact 
dental  arches.  Partial  fractures  of  the  alveolar 
region  heal  admirably;  and  we  must  never  yield  to 
the  temptation  to  elevate  the  bony  fragments, 
although  barely  held  up  by  the  flaps  of  mucosa  while 
the  teeth  totter  in  their  sockets.  A  conservative 
regime  is  always  indicated,  and  some  time  ago 
Malgaigne  enunciated  as  a  principle  that  all  splinters, 


INTERMAXILLARY  DISRUPTION  333 

no  matter  how  feebly  adherent,  should  be  reHgiously 
preserved.  The  best  treatment  for  these  fractures 
consists  in  applying  a  trough,  which  is  sealed  on  to 
the  teeth  supported  by  the  fragment,  and  on  to 
neighbouring  teeth.  This  trough  should,  of  course, 
be  made  to  a  mould,  taken  after  reducing  the  fracture. 
It  should  be  added  that  the  reduction  of  fractures 
of  the  maxilla  is  in  general  much  easier  than  fractures 
of  the  mandible,  for,  in  contrast  with  the  latter, 
we  have  not  to  struggle  against  displacements 
started  by  muscular  contraction.  There  are  cases 
when  the  teeth  offer  no  adequate  support;  in  such 
a  sealed  trough  is  contra-indicated.  We  substitute 
a  big  rubber  trough,  covering  the  palatine  vault,  and 
also  imprisoning  the  alveolar  fragments  to  keep  them 
reduced,  when  we  cannot  act  on  them  through  the 
intermediary  of  the  teeth. 


CHAPTER  III 

TREATMENT  OF  INTERMAXILLARY 
DISRUPTIONS 

This  consists  in  keeping  in  contact  the  maxillae, 
which  have  been  rent  asunder  in  the  mid-Une.  To 
do  this  easily,  a  trough  surrounds  the  whole  of  the 
arch,  and  is  continuous  with  a  large  palatine  plate. 
It  goes  without  saying  that  the  appHance  should  be 
made  to  a  corrected  mould,  so  as  to  get  consolidation 
without  disturbing  the  integrity  of  the  interdental 


334  INJURIES  OF   THE  FACE  AND  JAW 

articulation.     When  the  disruption  is  considerable, 
Font's  appliance  is  suitable.     This  is  a  palatine  plate 


Fig.    i6i. — Font's  Appliance  for  Fracture  of  the  Maxilla. 

divided  in  the  middle    line,   its   two  halves    being 
approximated  by  elastic  traction. 


CHAPTER  IV 

TREATMENT  OF  THE  HORIZONTAL  FRACTURE 
OF  GUERIN 

Since  the  track  lies  horizontally  above  the  palatine 
vault,  the  fragment  formed  by  the  vault  plus  the 
intact  dental  arch  tends  to  become  slightly  depressed* 
Therefore  it  is  wise  to  insure  its  good  coaptation  with 
the  upper  part  of  the  two  maxillse  by  an  elastic 
chin-band,  or  by  a  sling,  which  holds  the  dental 
arch  in  articulation  with  the  mandible  while  lifting 
it  up. 


FRACTURE  OF  GU&RIN  355 

CI.  Martin's  Appliance, — CI.  Martin  has  used  the 
following  neat  method:  On  a  palatine  plate  we  place 
springs,  as  for  a  denture,  giving  them  as  a  point 
d'apptii  either  a  lower  denture  or  a  gutter  on  the 
lower  arch.  When  inserted,  this  appliance,  by  the 
pressure  of  its  springs,  keeps  the  palatine  vault  in 


Fig.   162. — Guerin's  Horizontal  Fracture. 

position,  and  enables  the  patient  to  eat  and  talk, 
sparing  him  the  necessity  of  wearing  a  bandage  or  of 
keeping  the  mouth  closed. 

Beltrami's  Appliance.* — This  ingenious  appliance 
has  been  invented  and  made  for  the  complete  fracture 
of  the  two  upper  jaws,  known  as  "  Guerin's  fracture  " 
(see  Fig.  162). 

The   appliance,   to   fit   which  engenders   no   pain, 

*  Beltrami,  "  Emergency  Appliance  to  retain  a  Compli- 
cated Fracture  of  the  Upper  Jaw,"  xiv^  Cong,  internat.  de 
Med.,  Madrid,  1903,  p.  99,  described  by  P.  Martinier. 


336 


INJURIES  OF  THE  FACE  AND  JAW 


has  enabled  a  patient  to  eat  at  once  with  ease, 
although  before  placing  it  any  jaw  movement  was  out 
of  the  question,  owing  to  the  mobility  of  the  lower 
part  of  the  maxilla,  which,  detached,  floated  like  a 
foreign  body  in  the  mouth  (Fig.  163).  At  the  end 
of  ten  days  consolidation  was  nearly  complete,  and 
the  sufferer  could  eat  solid  food. 

The  treatment   comprises  the  following  different 
stages  : 


Fig.   163. — Beltrami's  Appliance  for  Guerin's  Fracture. 

1.  Taking  the  impression  of  the  fractured  upper 
jaw. 

2.  Stamping  a  plate  in  the  ordinary  way,  this  plate 
covering  all  the  teeth. 

3.  Trial  of  the  plate  to  see  that  it  fits,  and  fixing 
two  hooks  to  it  by  soldering.  Making  a  skull-cap 
with  tapes  for  attachment  to  the  hooks,  and  pressing 
the  fractured  part  upwards  and  backwards,  holding 
it  firmly. 


PRESTAT'S  APPLIANCE  337 

The  qualities  which  this  appUance  shows  may  be 
summed  up: 

{a)  Ease  in  fitting;  absence  of  pain. 

(6)  The  appHance  becomes  fixed  without  any 
trouble  or  dragging;  it  is  hardly  visible. 

(c)  Mastication  and  speech  are  quickly  achieved. 

Prestafs  Appliance.* — 'To  fix  a  palatine  vault 
which  has  been  separated  from  the  rest  of  the  maxilla 
by  trauma,  Prestat  uses  two  bands  of  silver,  15  cm. 
long  and  2  cm.  wide;  he  gives  them  the  shape  of  an 
S -curve,  so  that  each  one  has  two  gutters,  one  for 
the  teeth  and  one  for  the  lips.  He  places  each  band 
near  to  the  labial  commissure,  on  the  canine  and 
first  premolar;  then  with  pincers  he  compresses  the 
gutter  which  is  now  on  the  teeth,  so  as  to  grasp  the 
latter  at  the  neck.  Lastly  he  gives  a  suitable  angle 
to  the  appliance,  and  fixes  the  whole  to  the  patient's 
cap  with  tapes. 

Richer's  Appliance. — On  a  patient  afflicted  with 
multiple  fractures  of  the  facial  bones.  Richer,,  after 
taking  a  mould  of  upper  and  lower  jaws,  constructed 
a  lower  appliance  covering  the  lower  incisors,  and  an 
upper  one  to  cap  the  incisors  and  premolars. 

A  small  vertical  gold  bar  between  upper  and  lower 
caps  at  the  level  of  the  canines  kept  open  a  space 
through  which  the  patient  could  be  fed.  On  each 
side,  lateral  to  this  bar  and  opposite  to  the  premolars, 
a  German  silver  hook  had  been  soldered.  This 
pointed  from  behind  forwards  as  far  as  the  labial 

*  Bouvet,  "  Demonstration  of  an  Appliance  for  Double 
Fractures  of  the  Upper  Jaw  "  (Communication  to  the  Inter- 
national Dental  Congress  of  1900). 

2Z 


330 


INJURIES  OF  THE  FACE  AND  JAW 


commissure;  then,  after  its  exit  from  the  mouth, 
doubled  on  itself  to  curve  backwards  along  the  cheek, 
against  which  it  lay.  The  caps  being  fixed  by 
cement  to  the  teeth,  the  maxillae  took  up  their  normal 
positions  as  soon  as  a  silicated  bandage  was  attached 
as  a  vertical  loop  to  the  hook  outside  the  cheek,  the 
bandage  then  passing  up  to  be  attached  to  the  head 
(Fig.  164).     The  appliances  (upper  and  lower)  were 


Fig.    164. — Richer's  Appliance. 

I,    Extrabuccal  hook;  2,  vertical  bands;  3,  horizontal 

bands. 

thus  kept  suspended  without  having  to  use  the  chin 
as  a  point  d'appui. 

Bouvet's  Appliance.* — In  devising  this  apparatus, 
the  author  says  he  was  inspired  by  that  invented  by 
Martin,  and  modified  by  Martinier,  for  fractures  of 
the  mandible. 

*  Bouvet,  "  Appliance  for  Double  Fractures  of  the  Upper 
Jaw  "  (Communication  to  the  International  Dental  Con- 
gress of  1900). 


BO U VET'S  APPLIANCE 


339 


"  This  is  the  undertying  principle:  A  metal  plate, 
firmly  enclosing  the  vault  of  the  palate  and  the 
alveolar  margin,  is  joined  to  a  casque  by  a  system 
of  jointed  rods,  which  enable  one  to  arrange  this 
plate  and  retain  it  in  position,  and,  it  follows,  to  keep 
the  maxilla  motionless.     Having  said  this  much,  let 


Fig.   165. — Bouvet's  Appliance. 

I,  Palatine  piece;  2,  cylindrical  rod;  3,  flat  rod;  4,  screw 
of  junction  with  casque;  5,  casque. 

US  describe  seriatim  the  pieces  of  the  apparatus — 
namely,  casque,  plate,  and  system  of  jointed  rods. 

"  The  casque  consists  of  three  bands  of  bent  steel, 
lined  with  leather.  The  horizontal  occipito-frontal 
band  can  be  tightened  behind  at  will,  by  means  of  a 
strap  and  buckle  at  its  two  ends.  The  sagittal  band 
has  a  free  posterior  end  (as  in  a  fencing  mask),  which 
grips  the"*  occiput.     The  third  band  is  in  a  coronal 


34©  INJURIES  OF  THE  FACE  AND  JAW 

plane,  and  unites  the  other  two.  The  horizontal 
band  has  on  its  lateral  parts,  in  front  of  the  coronal 
band,  a  horizontal  window  8  cm.  long  and  i  cm. 
wide.  In  this  moves  a  small  round  sliding  bar, 
continued  outwards  into  a  screw.  The  palatine  plate 
(which  is  the  fundamental  piece)  is  of  platinum;  thus 


Fig.   i66. — Bouvet's  Appliance  in  Position. 

I,  Palatine  piece;  2,  cylindrical  rod;  3,  flat  rod;  4,  screw 
for  junction  to  casque;  5,  casque. 

we  can  give  it  great  strength  with  only  a  slight 
thickness.  It  is  made  to  a  mould  of  the  palate  and 
dental  arch.  The  gaps  between  teeth  and  the  spaces 
where  teeth  are  missing  may  be  used  to  unite  the 
palatine  part  to  the  parts  covering  the  outer  alveolar 
surfaces. 


BOUVET'S  APPLIANCE  341 

"  The  system  of  articulation  comprises  a  solid  flat 
triangular  metal  plate,  pierced  above  by  a  hole  for 
the  screw  to  pass  freely  through.  This  plate  is 
recurved  below  at  a  right  angle,  to  make  a  little 
platform,  perforated  in  its  centre  for  the  cyhndrical 
rod.  This  rod  is  tapped  with  a  screw-thread,  and 
carries  two  nuts,  the  smaller  of  which  is  on  top  of 
the  larger.  After  a  vertical  downward  course  of 
10  cm.,  the  cylindrical  rod  turns  forwards  at  a  right 
angle;  after  another  9  cm.  it  turns  inwards  in  a  semi- 
circle; finally  it  becomes  rectangular  in  section,  and 
is  soldered  to  the  external  surface  of  the  palatine 
plate.  The  angular  parts  of  the  rod  will  have  been 
tempered,  which  gives  them  a  reliable  amount  of 
resistance  to  bending.  The  end  of  the  rod  is  rect- 
angular in  section,  for  the  firmer  soldering  to  the 
palatine  plate. 

"  Let  us  now  see  how  the  parts  act.  We  put  on 
the  casque,  and  tighten  the  strap  to  hold  it  well  in 
place.  The  palatine  plate  is  put  into  position  in 
the  mouth,  and  the  two  cylindrical  rods  passed 
through  the  holes  into  the  platform  above.  The 
small  top  screw  is  passed  through  the  triangular  flat 
plate,  and  the  nut  screwed  on  loosely.  The  round 
sliding  bar,  continuous  with  the  small  top  screw, 
can  slide  in  the  window  of  the  occipito-frontal  band. 
The  upper  flat  triangular  plate  can  oscillate  around 
the  screw;  and  when  its  position  is  as  desired,  the 
nut  is  to  be  tightened.  The  cylindrical  rods  are  now 
adjusted  by  means  of  their  nuts,  two  on  each  rod. 
The  advantage  of  this  scheme  is  that  it  enables  the 
surgeon  to   direct  the  maxilla   (which  is  embodied 


342  INJURIES  OF  THE  FACE  AND  jAW 

in  the  palatine  plate)  at  his  will.  He  can  raise 
or  lower  it,  bring  it  forwards  or  backwards.  When 
the  whole  is  in  position,  it  is  impossible  to  get  the 
slightest  displacement." 


CHAPTER  V 
TREATMENT  OF  CRANIO-FACIAL  SEVERANCE 

The  object  of  this  should  be  to  keep  up  and  back 
the  facial  scaffolding  which  has  been  displaced 
downwards  and  forwards.  To  achieve  this  we  can 
contrive  apparatus  taking  its  point  d'appui  either 
from  the  cranial  vertex  (appliances  of  Graefe  and  of 
Goffres),  or  from  the  mandible  (appliance  of  Martin). 
We  have  already  described  Martin's  appliance, 
apropos  of  horizontal  fractures;  it  has  the  merit  of 
causing  no  worry  to  the  patient,  and,  although  its 
springs  act  feebly,  it  is  adequate.  In  the  majority 
of  cases,  in  fact,  the  displacements  to  be  corrected 
are  small  and  easy  to  reduce. 

Graefe's  Appliance  consists  of  a  steel  forehead 
band,  comfortably  fitted,  and  kept  in  place  by  a 
strap  and  buckle  behind  the  head.  On  each  side  a 
steel  rod  descends.  This  curves  inwards  and  slightly 
upwards  opposite  the  labial  commissure,  and  ends 
in  a  hook  which  grasps  the  alveolar  margin  of  the 
upper  dental  arch.  The  steel  rods,  sliding  in  a  slot 
on  the  frontal  band,  can  be  fixed  by  pressure-screws. 
The  appliance  being  in  place,  we  obtain  the  elevation 


CRANIO-FACIAL  SEVERANCE 


343 


of  the  whole  facial  framework  by  sUding  the 
rods  up  and  down,  fixing  them  by  the  screws  so 
as  to  maintain  the  amount  of  traction  deemed 
necessary. 


Fig.    167. — Graefe's  Appliance. 

A,  Forehead  band;  BD,  B'D',  metal  rods  ending  below  in 
hooks  which  lift  the  upper  jaws;  CC,  sliding  bearings. 

Goffres*  Appliance  depends  on  the  same  principle 
as  Graefe's.  It  differs  in  the  arrangement  of  the 
traction  rods,  which  are  closer  to  the  middle  line, 
and  ascend  each  side  of  the  nose  to  be  fixed  at  the 
forehead  level  by  pressure-screws.  The  advantage 
of  Goffres'  appliance  is  that  it  insures  a  more  equal 


344 


INJURIES  OF  THE  FACE  AND  JAW 


pull  on  the  two  rods,  because  they  are  close  to  the 
middle  line. 

In  the  case  of  Walter's  fracture  in  four  fragments, 
the  apparatus  used  for  cranio -facial  severance  is 
indicated — with  this  proviso,  that,  if  we  are  dealing 


Fig,   1 68. — Goffres'  Appliance. 

AA'C,  Tapes;  BB',  metal  rods  ending  in  hooks,  DD',  which 
lift  the  upper  jaw. 

with  the  appliance  of  Goffres  or  of  Graefe,  we  must 
add  a  trough  furnished  with  a  large  palatine  plate, 
to  reduce  intermaxillary  disruption.  The  palatine 
plate  will  oppose  any  tendency  of  the  traction  rods 
to  make  the  fragments  swing  outwards,  which  would 


CONCLUSION  345 

increase  the  intermaxillary  disruption.  There  are 
surgeons  who  uncompromisingly  reject  all  appli- 
ances, and  recommend  the  systematic  treatment  of 
upper  jaw  fractures  by  suture  of  bone.  We  need 
not  repeat  the  arguments  which  have  led  us  to  give 
up  bony  suture  for  fractures  of  the  mandible.  These 
arguments  apply  just  as  forcibly  to  fractures  of  the 
maxilla.  Let  us  in  conclusion  quote  the  words  of 
CI.  Martin:* 

"  In  these  fractures  of  both  upper  and  lower  jaws, 
it  is  always  the  upper  which  is  cured  more  speedily. 
Such  is  the  vitality  of  its  bony  tissue  that,  even 
when  splintered  into  many  fragments,  it  reshapes 
itself  very  easily;  and  there  is  no  real  difficulty  in 
arranging  retention  appliances." 

*  Cl.  Martin,  "  Treatment  of  Fractures  of  the  Mandible  " 
(Cong,  de  Chirurgie,  Paris,  1908,  p.  21). 


Bat/hire,  Tindall  and  Cox,  8,  Henrietta  Street,  Coveni  Garden 


COLUMBIA  UNIVERSITY  LIBRARIES 


This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

aaaa5aX®KFii 

-SEP  8  ^ : 

^'  v;^ 

c 

T^ 

V 

C28(1  140)  Ml  00 

